USOO8426439B2

(12) UnitedO States Patent (10) Patent No.: US 8.426,439 B2 Ciccocioppo (45) Date of Patent: *Apr. 23, 2013

(54) COMPOSITIONS AND METHODS FOR 7,510,728 B2 3/2009 Koike ...... 424/464 PROPHYLAXIS AND TREATMENT OF 7,517,900 B2 4/2009 Pendri et al. . ... 514,404 7,524,975 B2 4/2009 Mae et al. ... 549,405 ADDCTIONS 2002fOOO6942 A1 1/2002 Davis ...... 514,369 2002fOO77320 A1 6/2002 Lohray et al. 514/226.2 (75) Inventor: Roberto Ciccocioppo, Camerino (IT) 2003/0069246 A1 4/2003 Darrow et al...... 514,245 2003/010.0587 A1 5/2003 Moinet et al...... 514,369 (73) Assignee: Omeros Corporation, Seattle, WA (US) 2003/0220373 Al 1 1/2003 Jaye et al. ... 514,342 2004/0028735 A1 2/2004 Kositprapa ... 424/468 2004/OO77525 A1 4/2004 Chapman et al. ... 514/2 - r 2004/0096499 A1 5/2004 Vaya et al. ... 424/468 (*) Notice: Subject to any disclaimer, the term of this 2004/0127443 A1 7/2004 Pershadsingh 514,44 patent is extended or adjusted under 35 2004/0204472 A1 10/2004 Briggs et al. . 514,406 U.S.C. 154(b) by 859 days. 2005, 00041 79 A1 1/2005 Pedersen ...... 514,342 2005, OO14786 A1 1/2005 Sun et al...... 514/313 This patent is Subject to a terminal dis- 2005, OO 14833 A1 1/2005 Clark et al...... 514,561 claimer. 2005, 0096331 A1 5/2005 Das et al. . 514,259.3 2005, 01711.1.0 A1 8, 2005 Yu et al...... 514,248 2006, OOO9518 A1 1/2006 Campbell et al. ... 514,522 (21) Appl. No.: 12/101,943 2006/0024365 A1 2/2006 Vaya et al. ... 424/468 (22) Filed: Apr. 11, 2008 2006/0059152 A1 3/2006 Nakamura ...... 707/7 (Continued) (65) Prior Publication Data FOREIGN PATENT DOCUMENTS CA 2589 393 12/2007 US 2009/0048232A1 Feb. 19, 2009 EP 1867994 A2 12/2007 (Continued) Related U.S. Application Data OTHER PUBLICATIONS Cohen et al. CB1 receptor antagonists for the treatment of nicotine (60) Provisional application No. 60/911,201, filed on Apr. addiction. Pharmacology, Biochemistry and Behavior 81. 387-395 11, 2007. (2005).* Ang, E. et al., “Induction of nuclear factor-kappaB in nucleus (51) Int. Cl. accumbens by chronic cocaine administration.” J. of Neurochem. A6 IK3I/44 (2006.01) 79:221-224, 2001. (52) U.S. Cl. Asanuma, M. et al., “Methamphetamine-induced increase in USPC S14/293: 514/342: 514/811 striatalNF-kappaB DNA-binding activity is attenuated in Superoxide (58) Field of- -Classification ------Search- - - ...... s s s1420s, dismutaseStase trrangenic ic mice,mice.” Molecular trainBrain researcR h 60:305-309, 514/342,811 Ashby, C. et al., “Acute Administration of the Selective D. Receptor See application file for complete search history. Antagonist SB-27701 1A Blocks the Acquisition and Expression of the Conditioned Place Preference Response to Heroin in Male Rats.” (56) References Cited Synapse 48:154-156, 2003. Continued U.S. PATENT DOCUMENTS ( ) 4,572,912 A 2/1986 Yoshioka et al...... so Primary Examiner - Barbara P Badio 4,582,839 A 4, 1986 Meguro et al. . 514/342 Assistant Examiner — Sara E Townsley 4,687,777 A 8/1987 Meguro et al. . 514,342 (74) Attorney, Agent, or Firm — Marcia S. Kelbon 4,725,610 A 2/1988 Meguro et al. . 514,369 4,775,687. A 10/1988 Meguro et al. . 514/369 (57) ABSTRACT 4,812,570 A 3/1989 Meguro et al. 546,280 The present invention relates to methods of treating or pre 5,965,584. A 10/1999 Ikeda et al. 514,342 venting addiction and relapse use of addictive agents, and g h '' A 58 With ...... SS treating or preventing addictive or compulsive behavior and k - W Cai Ca. . 6,437,143395 B2B 5368/2002 MoinetWinstal. et al. ..O. ... Saito548, 183 EEEEEEg a p some p ited recept 6,506,762 B1 1/2003 Horvath et al. 514,2594 gamma (PPARy). agonist, alone or in combination with 6,582,738 B2 6/2003 Gubler ...... 426, 5 another therapeutic agent, such as, for example, an opioid 6,620,830 B2 9/2003 Chiang ...... 514,369 receptor antagonist or an antidepressant. The present inven 6,794,154 B1 9/2004 Yamanouchi et al. 435/7.8 tion also includes pharmaceutical compositions for treating 7,037,910 B2 5/2006 Ewing et al...... 514,243 or preventing addiction or relapse that include a PPARYago 7,067,530 B2 6/2006 Jeppesen et al...... 514,311 nist and one or more other therapeutic agents, as well as unit 7,141,561 B2 11/2006 Schwinket al...... 51421203 dosage forms of Such pharmaceutical compositions, which 7.312,229 B2 12/2007 Dankulich et al...... 514/284 contain a dosage effective in treating or preventing addiction 7,319, 170 B2 1/2008 Sahoo et al...... 564/43 1 Th thods and iti fthei ti 7,326,706 B2 2/2008 Ellsworth et al. .. 514,241 orrelapse. I nemeunoas and compositions oIune invention are 7,335,799 B2 2/2008 Dasseux et al...... 568,861 useful in the treatment or prevention of addiction to any agent, 7,365,064 B2 4/2008 Bhuniya et al. 514,230.5 including alcohol, nicotine, marijuana, cocaine, and amphet 7,378.418 B2 5, 2008 Yu et al...... 514,248 amines, as well as compulsive and addictive behaviors, 7,381,736 B2 6/2008 Cheruvallath et al...... 514,370 including pathological gambling and pathological overeat 7,411,071 B2 8/2008 Yang et al...... 548,195 ing 7,429,575 B2 9, 2008 Yu et al...... 514,114 7,446,110 B2 11/2008 Kaufman et al...... 514,284 38 Claims, 25 Drawing Sheets US 8,426.439 B2 Page 2

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Boyault, Sandrine et al., “15-Deoxy-6' '-PGJ, but not Kobayashi, Tetsuya et al., “Pioglitazone, a Peroxisome Proliferator troglitaZone, modulates IL-13 effects in human chondrocytes by Activated Receptor Y Agonist, Reduces the Progression of Experi inhibiting NF-kB and AP-1 activation pathways.” FEBS 501:24-30, mental Osteoarthritis in Guinea Pigs.” Arthritis & Rheumatism 2001. 52(2):479-487, 2005. Cheng, Saranette et al., “Activation of Peroxisome Proliferator-acti Koufany, Meriem et al., “Anti-inflammatory effect of antidiabetic vated Receptor Y Inhibits Interleukin-1B-induced Membrane-associ thiazolidinediones prevents bone resorption rather than cartilage ated Prostaglandin E Synthase-1 Expression in Human Synovial changes in experimental polyarthritis.” Arthritis Research & Therapy Fibroblasts by Interfering with Egr-1.” The Journal of Biological 10:R6, 2008. Chemistry 279(21): 22057-22065, 2004. Matsumoto, Takayuki et al., “Mechanisms underlying the chronic Cheng, S. et al., “Association of polymorphisms in the peroxisome pioglitaZone treatment-induced improvement in the impaired proliferator-activated receptor Y gene and osteoarthritis of the knee.” endothelium-dependent relaxation seen in aortas from diabetic rats.” Ann Rheum Dis 65:1394-1397, 2006. Free Radical Biology & Medicine 42:993-1007, 2007. Doi, Shigehiro et al., “Protective Effects of Peroxisome Proliferator Matsumoto, Takayuki et al., “Relationships among ET-1, PPARY, Activated Receptor Y Ligand on Apoptosis and Hepatocyte Growth oxidative stress and endothelial dysfunction in diabetic animals. J. Factor Induction in Renal Ischemia-Reperfusion Injury.” Transplan Smooth Muscle Res. 44(2):41-55, 2008. tation 84(2):207-213, 2007. Moulin, David et al., “Rosiglitazone Induces Interleukin-1 Receptor Fahmi, Hassan et al., “Peroxisome Proliferator-Activated Receptory Antagonist in Interleukin-1B-Stimulated Rat Synovial Fibroblasts Activators Inhibit Interleukin-1B-Induced Nitric Oxide and Matrix via a Peroxisome Proliferator-Activated Receptor B/ö-Dependent Metalloproteinase 13 Production in Human Chondrocytes.” Arthritis Mechanism.” Arthritis & Rheumatism 52(3):759-769, 2005. & Rheumatism 44(3):595-607, 2001. Moulin, David et al., “Effect of Peroxisome Proliferator Activated Fahmi, H. et al., “Peroxisome proliferator-activated receptor gamma Receptor (PPAR)Yagonists on prostaglandins cascade in joint cells.” activators inhibit MMP-1 production in human synovial fibroblasts Biorheology 43:561-575, 2006. likely by reducing the binding of the activator protein 1.” Poleni, P. E. et al., "Agonists of peroxisome proliferators-activated Osteoarthritis and Cartilage 10:100-108, 2002. receptors (PPAR)O, B/ö or Y reduce transforming growth factor Fahmi, H. et al., “PPARY Ligands as Modulators of Inflammatory and (TGF)-3-induced proteoglycans' production in chondrocytes.” Catabolic Responses in Arthritis. An Overview.” The Journal of Rheumatology 29(1):3-14, 2002. OsteoArthritis and Cartilage 15:493-505, 2007. Fahmi, H. et al., "15d-PG.J. is acting as a 'dual agent on the regula Simonin, Marie-Agnes et al., “PPAR-Y ligands modulate effects of tion of COX-2 expression in human osteoarthritic chondrocytes.” LPS in stimulated ratsynovial fibroblasts.” Am J Physiol Cell Physiol Osteoarthritis and Cartilage 10:845-848, 2002. 282:C125-C133, 2002. Farrajota, Katherine et al., “Inhibition of interleukin-1beta-induced http://www.cwru.edu/med psychiatry/bipolar?handouts/ cyclooxygenase 2 expression in human synovial fibroblasts by PioglitaZone handout - What is pioglitaZone.pdf, Jun. 2010. 15-deoxy-Delta12, 14-prostaglandin J2 through a histone Derosa, G. et al., “Pioglitazone and Sibutramine Combination deacetylase-independent mechanism.” Arthritis & Rheumatism Effects on Glucose and Lipid Metabolism in Obese Type 2 Diabetic 52(1):94-104, 2005. Patients. NMCD. Nutrition Metabolism and Cardiovascular Dis Haraguchi, Tamami et al., “Cerebroprotective action of telmisartan eases, Milan Italy, 14(5):310 (2004). by inhibition of macrophages/microglia expressing HMGB1 via a Choi, J. et al., “Exposure to Rosiglitazone and Fluoxetine in the First peroxisome proliferator-activated receptor Y-dependent mechanism.” Trimester of Pregnancy.” Diabetes Care LNKD PubMed. Neuroscience Letters 464:151-155, 2009. 16936 175, 29(9):2176 (2006). Hirano, Mitsumasa et al., “Rapid improvement of carotid placque Bao, Z. et al., “Influence of Peroxisome Proliferator-activated Recep echogenicity within 1 month of pioglitaZone treatment in patients tor Gamma on Airway inflammation of Guinea Pigs with Asthma.” with acute coronary syndrome.” Atherosclerosis 203:483-488, 2009. Chinese Journal of Tuberculosis and Respiratory Diseases, Jouzeau, JY et al., “Pathophysiological relevance of peroxisome Zhonghua Yixuehui, Beijing, China, 27(3): 169-173 (English proliferators activated receptors (PPAR) to joint diseases—the pro abstract) (2004). and con of agonists.”J Soc Biol. 202(4):289-312, 2008. AcuroXR (oxycodone HCI, USP and niacin, USP) Tablets, NDA Jouzeau, Jean-Yves et al., “Role des recepteurs actives par les 22-451, Briefing Information for a Joint Meeting of the Anesthetic proliferateurs de peroxysomes (PPAR) en physiopathologie and Life Support Drugs Advisory Committee and Drug Safety and articulaire: interest et limites des agonists.” Journal de la Societe de Risk Management Advisory Committee, Apr. 22, 2010. Acura Phar Biologie 202(4):289-312, 2008. maceuticals, Inc. Kalajdzic, Tanja et al., “NimeSulide, a Preferential Cyclooxygenase 2 Omeros Corporation Press Release, Omeros Announces Expansion Inhibitor, Suppresses Peroxisome Proliferator-Activated Receptor of Exclusivity License to PDE7 Inhibitors from Daiichi Sankyo: Induction of Cyclooxygenase 2 Gene Expression in Human Synovial Promising Data for the Treatment of Addiction and Compulsive Fibroblasts: Evidence for Receptor Antagonism.” Arthritis & Rheu Disorders. Seattle, Feb. 22, 2011, PRNewswire via COMTEX. matism 46(2):494-506, 2002. Maeda, T., et al., “Peroxisome proliferator-activated receptor gamma Kanie, Noriyasu et al., “Relationship between peroxisome prolifera activation relieves expression of behavioral sensitization to tor-activated receptors (PPARO and PPARY) and endothelium-de methamphetamine in mice.” Neuropsychopharmacology 32: 1133 pendent relaxation in Streptozotocin-induced diabetic rats. British 1140 (2007). Journal of Pharmacology 140:23-32, 2003. Lallemand, F., et al., “SR147778, a CB1 cannabinoid receptor Keller, Jean Marie et al., “Implications of Peroxisome Proliferator antagonist, Suppresses ethanol preference in chronically alcoholized Activated Receptors (PPARS) in development, cell life status and Wistar rats.” Alcohol 39(3):125-34 (2006). (Abstract only). disease.” Int. J. Dev. Biol. 44:429-442, 2000. Newton, T.F., et al., “Bupropion reduces methamphetamine-induced Kobayashi, Tetsu et al., “Changes in peroxisome proliferator-acti Subjective effects and cue-induced craving.” vated receptor Y-regulated gene expression and inhibin/activin-fol Neuropsychopharmacology 31: 1537-1544 (2006). listatin system gene expression in rattestis after an administration of di-n-butyl phthalate.” Toxicology Letters 138:215-225, 2003. * cited by examiner U.S. Patent Apr. 23, 2013 Sheet 1 of 25 US 8,426,439 B2

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Veh pio 30 mg/kg FIG. 23B US 8,426,439 B2 1. 2 COMPOSITIONS AND METHODS FOR ing results none of these medications, including naltrexone, is PROPHYLAXIS AND TREATMENT OF of Sufficient efficacy in alcoholism and prognosis remains ADDCTIONS poor. Nicotine is one of the most widely used addictive drugs, CROSS-REFERENCE TO RELATED and nicotine abuse is the most common form of Substance APPLICATION abuse. The WHO estimates that there are 1.25 billion Smokers worldwide, representing one third of the global population This application claims the benefit under 35 U.S.C. S 119 over the age of 15. The WHO further estimates that 5 million (e) of U.S. Provisional Patent Application No. 60/911,201 deaths occur each year as a direct result of tobacco use, filed Apr. 11, 2007, where this provisional application is 10 making nicotine abuse the largest single preventable cause of incorporated herein by reference in its entirety. death worldwide. In industrialized countries, 70-90% of lung cancer, 56-80% of chronic respiratory disease, and 22% of BACKGROUND cardiovascular disease instances are attributed to nicotine 15 addiction. Cigarette smoking is associated with 430,000 1. Technical Field deaths a year in the US alone and is estimated to cost the The present invention is directed generally to the treatment nation 80 billion dollars yearly in health care costs. Tobacco or prevention of addictions using PPARYagonists, alone or in use accounts for one third of all cancers, including cancer of combination with other therapeutic agents. the lung, mouth, pharynx, larynx, esophagus, cervix, kidney, 2. Description of the Related Art ureter, and bladder. The overall rates of death from cancer are The World Health Organization (WHO) defines substance twice as high among Smokers as among nonsmokers. Smok addiction as using a Substance repeatedly, despite knowing ing also causes lung diseases such as chronic bronchitis and and experiencing harmful effects. Substance addiction is a emphysema; exacerbates asthma symptoms; and increases chronic, relapsing disease characterized by a loss of control the risk of heart disease, including stroke, heart attack, vas over drug use, compulsive drug seeking and craving for a 25 cular disease, and aneurysm. An estimated 20% of the deaths Substance, use that persists despite negative consequences, from heart disease are attributable to Smoking. Expectant and physical and/or psychological dependence on the Sub women who Smoke are at greater risk than nonsmokers for stance. Substance addiction typically follows a course of premature delivery, spontaneous abortion, and infants with tolerance, withdrawal, compulsive drug taking behaviour, decreased birth weight. drug seeking behaviour, and relapse. Substance abuse and 30 Nicotine use results in increased levels of the neurotrans addiction are public health issues with significant Social and mitter dopamine, which activates the reward pathways to economic impact on both the addict and society by playing a regulate feelings of pleasure and to mediate the desire to major role in violent crime and the spread of infectious dis consume nicotine. Symptoms associated with nicotine with eases. Addictive Substances include alcohol, caffeine, nico drawal include craving, irritability, anger, hostility, aggres tine, cannabis (marijuana) and cannabis derivatives, opiates 35 Sion, fatigue, depression, and cognitive impairment, which and other morphine-like opioid agonists such as heroin, phen lead the abuser to seek more nicotine. Environmental condi cyclidine and phencyclidine-like compounds, sedative ipnot tioning factors and exposure to psychological stress represent ics Such as benzodiazepines and barbiturates and psycho additional factors motivating nicotine use in Smokers. stimulants such as cocaine, amphetamines and amphetamine Repeated nicotine use results in the development of tolerance, related drugs such as dextroamphetamine and 40 requiring higher doses of nicotine to produce the same initial methylamphetamine. stimulation. Alcohol is one of the most commonly abused substances at Most therapies developed for nicotine addiction have a global level. Additionally, alcoholism leads to serious liver shown only moderate Success in preventing relapse, leading and cardiovascular disease and generates dependence result to a high failure rate in attempts to quit Smoking. Treatments ing in severe mental disorders, social problems and adverse 45 include the use of nicotine replacement products, anti-depres consequences including the division of families, tragic acci sants, anti-hypersensitives, and behavioural therapy. dents and the reduction of work performance. According to The National Institute on Drug Abuse estimates that 72 the WHO, alcohol consumption is responsible for 20-30% of million Americans, about one third of the population, have oesophageal and liver cancer, liver cirrhosis, homicides, epi tried marijuana. Acute effects of marijuana use include lepsy, and motor vehicle accidents world wide. Globally, 50 memory and learning problems, distorted perception, diffi alcohol abuse leads to about 1.8 million deaths per year. culty problem solving, loss of coordination, and increased Compulsive behaviour towards the consumption of alcohol is heart rate. Long term abuse can cause the same respiratory a core symptom of the disorder. In recent years several problems observed in tobacco smokers, such as daily cough, approaches have been investigated to help alcoholic patients phlegm production, increased risk of lung infections, and an to not only control alcohol drinking but also alcohol cravings 55 increased chance of developing cancer of the head, neck and and relapse (Montietal., 1993; Volpicellietal. 1992: O'Brien lungs. Depression, anxiety, and job-related problems have et al. 1997). been associated with marijuana use. Longterm marijuanause Medications such as naltrexone, acamprosate, can result in addiction with compulsive use that interferes ondansetron, disulfiram, gamma hydroxybutyrate (GHB), with daily activities. Cravings and withdrawal symptoms, and topiramate tested for their potential therapeutic effect on 60 Such as irritability, increased aggression, sleeplessness, and alcohol abuse belong to several classes (Volpicellietal. 1992: anxiety make it difficult for addicts to stop using marijuana. O'Brien et al. 1997). Few of these pharmacotherapeutics, There are no pharmaceutical treatments available for treating Such as naltrexone, acamprosate, and disulfiram, have been marijuana addiction and relapse. proven to be of a certain utility and approved for the treatment According to the WHO, an estimated 13 million people of alcoholism. Among these medications, the non-selective 65 abuse opiates worldwide, including 9 million heroin addicts. opioidantagonist naltrexone is currently considered the phar More than 25% of opiate abusers die from suicide, homicide, macological gold standard. However, despite some promis or an infectious disease, such as HIV and hepatitis, within US 8,426,439 B2 3 4 10-20 years of becoming addicted. Tolerance and physical that are thought to underlie anxiety, mood dysregulation and dependence can develop within two to three days. Somatic symptoms that accompany acute withdrawal, and The goals for treatment of opiate addiction, as with other that can persist for considerable periods of time during what types of substance addictions, are to discontinue the use of the has been referred to as the “protracted withdrawal' phase. opiate while minimizing painful withdrawal symptoms and 5 This view, therefore, implicates alleviation of discomfort and preventing relapse. Current treatments involve replacing the negative affect as a motivational basis for relapse. addictive drug with a substitution of an opioid receptor ago Conditioning hypotheses are based on observations that nist or mixed agonist/antagonist. An alternative approach relapse is often associated with exposure to drug-related envi consists of the use of an opioid receptor antagonist to block ronmental stimuli. This view holds that specific environmen the effect of the agonist. Antagonists provide no relief from 10 tal stimuli that have become associated with the rewarding pain or other withdrawal symptoms; rather, they can precipi actions of a drug by means of classical conditioning can elicit tate withdrawal, and their therapeutic use was associated with Subjective states that trigger resumption of drug use. The increased accidental opioid agonists overdosing and homeostatic and conditioning hypotheses are not mutually increased lethality. Use of agonists with a lower affinity for exclusive. In fact, homeostatic and conditioning factors are the receptors results in the least severe withdrawal symptoms, 15 likely to exert additive effects in that exposure to drug-related but it can lead to a dependence on the Substitute opiate. Also, environmental stimuli may augment Vulnerability to relapse many Substitution therapies take 3-6 months, allowing time conveyed by homeostatic disturbances. for addicts to stop treatment midway. Clearly, there is a need in the art for new methods for Psychostimulants, such as cocaine and amphetamines, treating and preventing addiction and the relapse use of addic cause euphoria, increased alertness, and increased physical tive agents. The present invention meets these needs by pro capacity in humans. These substances first increase dopamine viding methods and pharmaceutical combinations useful in transmission, but long term drug usage results in a reduction treating and preventing addiction and recividism. of dopamine activity, leading to dysregulation of the brain reward system and dysporia. The WHO estimates 33 million BRIEF SUMMARY people around the world abuse amphetamines. 25 Chronic cocaine abuse can result in hyperstimulation, The present invention is directed generally to the use of tachycardia, hypertension, mydriasis, muscle twitching, PPARY agonists, alone or in combination with one or more sleeplessness, extreme nervousness, hallucinations, paranoia, additional therapeutic agents, for the treatment and preven aggressive behaviour, and depression. Cocaine overdose may tion of addictions and relapse to addictive use or behavior. lead to tremors, convulsions, delirium, and death resulting 30 Accordingly, the present invention provides methods and from heart arrhythmias and cardiovascular failure. related compositions, unit dosage forms, and kits useful for Desipramine, amantadine and bromocriptine have been the treatment and prevention of addictions, and for the treat shown to decrease cocaine withdrawal symptoms. ment and prevention of relapse use of addictive agents or Amphetamine withdrawal symptoms include EEG practice of addictive or compulsive behaviours. changes, fatigue, and mental depression. Tolerance develops 35 In one embodiment, the present invention includes a over time and may be associated with tachycardia, auditory method of treating or preventing an addiction, comprising and visual hallucinations, delusions, anxiety reactions, para determining that a Subject has or is at risk of developing an noid psychosis, exhaustion, confusion, memory loss, and pro addiction, and providing to the Subject an amount of an ago longed depression with Suicidal tendencies. Current treat nist of a peroxisome proliferator-activated receptor gamma ments for amphetamine addiction include phenothiazines, 40 (PPARYagonist) effective for the treatment or prevention of haloperidol, and chlorpromazine for hallucinations, but the addiction. potential side effects of these drugs include postural hypoten In a related embodiment, the present invention provides a sion and severe extrapyramidal motor disorders. method of treating or preventing an addiction, comprising In the past, treatment for Substance addictions focused on providing to a subject having an addiction a peroxisome behavioural therapy, but dependence on many of these highly 45 proliferator-activated receptor gamma (PPARY agonist) and addictive Substances is hard to break. In particular, addictions an additional therapeutic agent, wherein each of the PPARY to alcohol, cocaine, and heroin are considered chronic, relaps agonist and the additional therapeutic agent contribute to the ing disorders. Also, concurrent abuse of multiple Substances, effective treatment or prevention of the addiction. Such as nicotine, heroin, cocaine and alcohol, is common. In certain embodiments of the methods of treating or pre The long-lasting, chronic nature of many addictions and 50 venting addiction of the present invention, the PPARYagonist high rates of recidivism present a considerable challenge for is a thiazolidinedione (TZD). In particular embodiments, the the treatment of drug and alcohol addiction, Such that under TZD is pioglitaZone, rosiglitaZone, ciglitaZone, troglitaZone, standing of the neurobiological basis of relapse has emerged englitaZone, rivoglitaZone, or darglidaZone. In certain as a central issue in addiction research. Emotional and envi embodiments, the additional therapeutic agent is an opioid ronmental factors (conditioning stimuli) were listed among 55 antagonist, a mixed opioid partial agonist/antagonist, an anti the main causes of relapse. For example, it is known that depressant, an antiepileptic, an antiemetic, a corticotrophin specific stress conditions such as loss of work and economic releasing factor-1 (CRF-1) receptor antagonist, a selective difficulties, or stimuli predictive of the presence of alcohol serotonin-3 (5-HT3) antagonist, a 5-HT2, antagonist, or a previously associated with its use such as a bottle of the cannabinoid-1 (CB1) receptor antagonist. In particular preferred wine and a bar-like environment, may strongly 60 embodiments, the opioid antagonist is naltrexone or facilitate relapse in detoxified former alcoholics. nalmefene. In particular embodiments, the antidepressant is Two major theoretical positions exist to explain the persis fluoxetine, mirtazapine, or bupropion. In particular embodi tence of addictive behaviour and vulnerability to relapse asso ments, the antiepileptic is topiramate, levetiracetam, orgaba ciated with drug and alcohol addiction, homoeostatic hypoth pentin. In one embodiment, the CRF-1 receptor antagonist is eses and conditioning hypotheses. 65 antalarmin. In another embodiment, the selective serotonin-3 Homeostatic hypotheses relate relapse risk to neuroadap (5-HT3) antagonist is ondansetron. In particular embodi tive changes and disruption of neuroendocrine homeostasis ments, the cannabinoid-1 (CB1) receptor antagonist is US 8,426,439 B2 5 6 rimonabant or tanarabant. In one embodiment, the mixed drug or may be a non-pharmacologic therapy Such as coun opioid agonist/antagonist is buprenorphine. Seling, psychotherapy or hypnosis therapy. In certain embodiments of the methods of the present In a related embodiment, the present invention includes a invention, the Subject is addicted to an addictive agent, or at method of preventing relapse use of an addictive agent or risk for relapse use of an addictive agent. In particular 5 practice of an addictive or compulsive behaviour, comprising embodiments, the addictive agent is alcohol, nicotine, mari providing an effective amount of a peroxisome proliferator juana, a marijuana derivative, an opioid agonist, a benzodi activated receptor gamma (PPARY agonist) to a subject who azepine, a barbiturate, or a psychoStimulant. In certain has undergone a period of abstinence from, or limited or embodiments, the opioid agonist is selected from the group reduced use of the addictive agent or practice of the addictive consisting of morphine, methadone, fentanyl, Sufentanil and 10 or compulsive behaviour, and also providing to the Subject an heroin. In certain embodiments, the psychostimulant is additional therapeutic agent, wherein each of the PPARYago cocaine, amphetamine oran amphetamine derivative. In addi nist and the additional therapeutic agent contribute to the tion, the subject may be addicted to more than one addictive effective prevention of the relapse use or practice. In certain agent, and the pharmaceutical compositions, unit dosage embodiments, the Subject has undergone physiological with forms, and kits may be useful for treating or preventing addic 15 drawal from the addictive agent during the period of absti tion or relapse use of more than one addictive agent. nence from, or limited or reduced use of the addictive agent In other embodiments of the present invention, the subject or due to no longer being exposed to an effective amount of is addicted to an addictive or compulsive behavior or at risk the anti-addiction treatment. for relapse practice of an addictive or compulsive behaviour. In another related embodiment, the present invention pro In particular embodiments, the addictive or compulsive vides a method of treating relapse use of an addictive agent or behavior is pathological gambling, pathological overeating, practice of an addictive or compulsive behaviour, comprising pathological use of electronic devices, pathological use of providing an effective amount of a peroxisome proliferator electronic video games, pathological use of electronic com activated receptor gamma (PPARY agonist) to a subject who munication devices, pathological use of cellular telephones, has undergone a period of abstinence from, or limited or addiction to pornography, sex addiction, obsessive compul 25 reduced use of the addictive agent or practice of the addictive sive disorder, compulsive spending, anorexia, bulimia, inter or compulsive behaviour. In certain embodiments, the Subject mittent explosive disorder, kleptomania, pyromania, tricho has undergone physiological withdrawal from the addictive tillomania, compulsive overexercising, and compulsive agent during the period of abstinence from, or limited or overworking. In addition, the Subject may be addicted to more reduced use of the addictive agent or due to no longer being than one addictive or compulsive behaviour, and the pharma 30 exposed to an effective amount of the anti-addiction treat ceutical compositions, unit dosage forms, and kits may be ment. useful for treating or preventing addiction or relapse use of In a further embodiment, the present invention includes a more than one addictive or compulsive behaviour. method of treating relapse use of an addictive agent or prac In particular embodiments of any of the methods of the tice of an addictive or compulsive behaviour, comprising present invention, the addictive agent is alcohol and the addi 35 providing an effective amount of a peroxisome proliferator tional therapeutic agent is an opioid antagonist or a mixed activated receptor gamma (PPARY agonist) to a subject who opioid antagonist/partial agonist. In one embodiment, the has undergone a period of abstinence from, or limited or opioid antagonist is naltrexone. In another embodiment, the reduced use of the addictive agent or practice of the addictive mixed opioid partial agonist/antagonist is buprenorphine. or compulsive behaviour, and also providing to the Subject an In other particular embodiments of any of the methods of 40 additional therapeutic agent wherein each of the PPARYago the present invention, the addictive agent is nicotine and the nist and the additional therapeutic agent contribute to the additional therapeutic agent is an antidepressant. In one effective treatment of the relapse use or practice. In certain embodiment, the antidepressant is bupropion. embodiments, the Subject has undergone physiological with In further particular embodiments of any of the methods of drawal from the addictive agent during the period of absti the present invention, the addictive agentis a psychoStimulant 45 nence from, or limited or reduced use of the addictive agent and the additional therapeutic agent is an antidepressant. In or due to no longer being exposed to an effective amount of one embodiment, the antidepressant is bupropion. the anti-addiction treatment. In other particular embodiments of any of the present In another related embodiment, the present invention pro invention, the subject is addicted to two or more addictive vides a method of preventing relapse use of an addictive agent agents and the additional therapeutic agent is an opioid 50 or practice of an addictive or compulsive behaviour, compris antagonist or a mixed opioid partial agonist/antagonist. In ing providing an effective amount of a peroxisone prolifera certain embodiments, the opioid antagonist is naltrexone or tor-activated receptor gamma (PPARY agonist) to a Subject, nalmefene. In other embodiments, the mixed opioid partial wherein the subject previously reduced or eliminated use of agonist/antagonist is buprenorphine. the addictive agent or practice of the addictive or compulsive In further related embodiments, the present invention pro 55 behaviour in response to treatment with an effective amount vides a method of preventing relapse use of an addictive agent of an anti-addiction treatment, and wherein the Subject is no or practice of an addictive or compulsive behaviour, compris longer exposed to an effective amount of the anti-addiction ing providing an effective amount of a peroxisome prolifera treatment. In certain embodiments, the Subject is no longer tor-activated receptor gamma (PPARY agonist) to a subject exposed to an effective amount of an anti-addiction agent who has undergone a period of abstinence from, or limited or 60 because the Subject has become conditioned to the anti-ad reduced use of the addictive agent or practice of the addictive diction agent. In certain embodiments, the Subject is no or compulsive behaviour. In certain embodiments, the Subject longer exposed to an effective amount of the anti-addiction has undergone physiological withdrawal from the addictive treatment because the subject has reduced or eliminated agent during the period of abstinence from, or limited or exposure to the anti-addiction treatment. reduced use of the addictive agent or due to no longer being 65 In a related embodiment, the present invention provides a exposed to an effective amount of the anti-addiction treat method of preventing relapse use of an addictive agent or ment. The anti-addiction treatment may be an anti-addiction practice of an addictive or compulsive behaviour, comprising US 8,426,439 B2 7 8 providing an effective amount of a peroxisone proliferator tor-activated receptor gamma (PPARY) agonist to a subject activated receptor gamma (PPARY agonist) to a subject, undergoing physiological withdrawal from an addictive wherein the subject previously reduced or eliminated use of agent. the addictive agent or practice of the addictive or compulsive In a related embodiment, the present invention provides a behaviour in response to treatment with an effective amount method of reducing one or more symptoms associated with of an anti-addiction treatment, and wherein the Subject is no physiological withdrawal from an addictive agent, compris longer exposed to an effective amount of the anti-addiction ing providing an effective amount of a peroxisome prolifera treatment, and also providing to the Subject an additional tor-activated receptor gamma (PPARY) agonist and an addi therapeutic agent, wherein each of the PPARYagonist and the tional therapeutic agent to a Subject undergoing physiological 10 withdrawal from an addictive agent, wherein each of the additional therapeutic agent contribute to the effective pre PPARY agonist and the additional therapeutic agent contrib vention of the relapse use or practice. In certain embodiments, ute to reducing one or more symptoms associated with physi the Subject is no longer exposed to an effective amount of an cal withdrawal from the addictive agent. anti-addiction agent because the Subject has become condi In particular embodiments of methods of reducing one or tioned to the anti-addiction agent. In certain embodiments, 15 more symptoms associated with physiological withdrawal the Subject is no longer exposed to an effective amount of the from an addictive agent according to the present invention, anti-addiction treatment because the Subject has reduced or the PPARY agonist is a thiazolidinedione (TZD). In certain eliminated exposure to the anti-addiction treatment. embodiments, the TZD is pioglitaZone, rosiglitaZone, cigli In additional embodiments, the present invention includes taZone, troglitaZone, englitaZone, rivoglitaZone or darglida a method of treating relapse use of an addictive agent or Zone. In certain embodiments, the additional therapeutic practice of an addictive or compulsive behaviour, comprising agent is an opioid antagonist, a mixed opioid partial agonist/ providing an effective amount of a peroxisone proliferator antagonist, an antidepressant, an antiepileptic, an antiemetic, activated receptor gamma (PPARY agonist) to a subject, a corticotrophin-releasing factor-1 (CRF-1) receptor antago wherein the subject previously reduced or eliminated use of nist, a selective serotonin-3 (5-HT3) antagonist, a 5-HT2, the addictive agent or practice of the addictive or compulsive 25 antagonist, or a cannabinoid-1 (CB1) receptor antagonist. behaviour in response to treatment with an effective amount In another embodiment, the present invention includes a of an anti-addiction treatment, and wherein the Subject is no pharmaceutical composition, comprising a peroxisome pro longer exposed to an effective amount of the anti-addiction liferator-activated receptor gamma (PPARY) agonist and an treatment. In certain embodiments, the Subject is no longer additional therapeutic agent, wherein each of the PPARYago 30 nist and the additional therapeutic agent contribute to the exposed to an effective amount of an anti-addiction agent effective treatment or prevention of an addiction. In certain because the subject has become conditioned to the anti-ad embodiments, the PPARY agonist is a thiazolidinedione diction agent. In certain embodiments, the Subject is no (TZD). In certain embodiments, the TZD is pioglitazone, longer exposed to an effective amount of the anti-addiction rosiglitaZone, ciglitaZone, troglitaZone, englitaZone, rivogli treatment because the subject has reduced or eliminated 35 taZone or darglidaZone. exposure to the anti-addiction treatment. In one embodiment, the pharmaceutical composition is In a further embodiment, the present invention includes a effective in the treatment of an addiction to an addictive agent. method of treating relapse use of an addictive agent or prac In particular embodiments, the addictive agent is alcohol, tice of an addictive or compulsive behaviour, comprising nicotine, marijuana, a marijuana derivative, an opioid ago providing an effective amount of a peroxisone proliferator 40 nist, a benzodiazepine, a barbiturate, or a psychoStimulant. activated receptor gamma (PPARY agonist) to a subject, In another embodiment, the pharmaceutical composition is wherein the subject previously reduced or eliminated use of effective in the treatment of an addiction to an addictive or the addictive agent or practice of the addictive or compulsive compulsive behaviour. In particular embodiments, the addic behaviour in response to treatment with an effective amount tive or compulsive behavior is pathological gambling, patho of an anti-addiction treatment, and wherein the Subject is no 45 logical overeating, pathological use of electronic devices, longer exposed to an effective amount of the anti-addiction pathological use of electronic video games, pathological use treatment, and also providing to the Subject an additional of electronic communication devices, pathological use of therapeutic agent, wherein each of the PPARYagonist and the cellular telephones, addiction to pornography, sex addiction, additional therapeutic agent contribute to the effective treat obsessive compulsive disorder, compulsive spending, anor ment of the relapse use or practice. In certain embodiments, 50 exia, bulimia, intermittent explosive disorder, kleptomania, the Subject is no longer exposed to an effective amount of an pyromania, trichotillomania, compulsive overexercising, and anti-addiction agent because the Subject has become condi compulsive overworking. tioned to the anti-addiction agent. In certain embodiments, In certain embodiments of pharmaceutical compositions of the Subject is no longer exposed to an effective amount of the the present invention, the additional therapeutic agent is an anti-addiction treatment because the Subject has reduced or 55 opioid antagonist, a mixed opioid partial agonist/antagonist, eliminated exposure to the anti-addiction treatment. an antidepressant, an antiepileptic, an antiemetic, a corti In particularembodiments of any of the methods of treating cotrophin-releasing factor-1 (CRF-1) receptor antagonist, a or preventing relapse use or practice of the present invention, selective serotonin-3 (5-HT3) antagonist, a 5-HT2, the PPARY agonist is pioglitazone and the additional thera antagonist, and a cannabinoid-1 (CB1) receptorantagonist. In peutic agent is naltrexone. 60 one embodiment, the opioid antagonist is naltrexone or In particularembodiments of any of the methods of treating nalmefene. In one embodiment, the antidepressant is fluox or preventing relapse use or practice of the present invention, etine, mirtazapine, or bupropion. In one embodiment, the the relapse use or relapse practice is stress-induced. antiepileptic is selected from the group consisting of topira In another embodiment, the present invention provides a mate, levetiracetam, and gabapentin. In one embodiment, the method of reducing one or more symptoms associated with 65 CRF-1 receptor antagonist is antalarmin. In one embodiment, physiological withdrawal from an addictive agent, compris the selective serotonin-3 (5-HT3) antagonist is ondansetron. ing providing an effective amount of a peroxisome prolifera In one embodiment, the cannabinoid-1 (CB1) receptor US 8,426,439 B2 10 antagonist is rimonabant or tanarabant. In one embodiment, ment of prevention of an addiction. In particular embodi the mixed opioid agonist/antagonist is buprenorphine. ments, the PPARY agonist is a thiazolidinedione (TZD). In In a particular embodiment of a pharmaceutical composi certain embodiments, the TZD is pioglitaZone, rosiglitaZone, tion of the present invention, the addictive agent is alcohol ciglitaZone, troglitaZone, englitaZone, rivoglitaZone or dargl and the additional therapeutic agent is an opioid antagonist or idazone. In certain embodiments, the additional therapeutic a mixed opioid antagonist/partial agonist. In one embodi agent is an opioid antagonist, a mixed opioid partial agonist/ ment, the opioidantagonist is naltrexone. In one embodiment, antagonist, an antidepressant, an antiepileptic, an antiemetic, the mixed opioid partial agonist/antagonist is buprenorphine. a corticotrophin-releasing factor-1 (CRF-1) receptor antago In a particular embodiment of a pharmaceutical composi nist, a selective serotonin-3 (5-HT3) antagonist, a 5-HT, tion of the present invention, the addictive agent is nicotine 10 antagonist, or a cannabinoid-1 (CB1) receptor antagonist. In and the additional therapeutic agent is an antidepressant. In one embodiment, the opioid antagonist is naltrexone or one embodiment, the antidepressant is bupropion. nalmefene. In one embodiment, the antidepressant is fluox In a particular embodiment of a pharmaceutical composi etine, mirtazapine, or bupropion. In one embodiment, the tion of the present invention, the addictive agent is a psycho antiepileptic is selected from the group consisting of topira stimulant and the additional therapeutic agent is an antide 15 mate, levetiracetam, and gabapentin. In one embodiment, the pressant. In one embodiment, the antidepressant is CRF-1 receptor antagonist is antalarmin. In one embodiment, bupropion. the selective serotonin-3 (5-HT3) antagonist is ondansetron. In a particular embodiment of a pharmaceutical composi In one embodiment, the cannabinoid-1 (CB1) receptor tion of the present invention, the addictive agent comprises antagonist is rimonabant or tanarabant. In one embodiment, two or more addictive agents and the additional therapeutic the mixed opioid agonist/antagonist is buprenorphine. agent is an opioidantagonist or a mixed opioid partial agonist/ In one particular embodiment of a kit of the present inven antagonist. In one embodiment, the opioid antagonist is nal tion, the PPARY agonist is pioglitazone and the additional trexone or nalmefene. In one embodiment, the mixed opioid therapeutic agent is naltrexone. partial agonist/antagonist is buprenorphine. In one particular embodiment of a kit of the present inven In a particular embodiment of a pharmaceutical composi 25 tion, the addictive agent is alcohol and the additional thera tion of the present invention, the PPARY agonist is pioglita peutic agent is an opioidantagonist or a mixed opioid antago Zone and the additional therapeutic agent is naltrexone. nist/partial agonist. In one embodiment, the opioidantagonist In further related embodiments, the present invention is naltrexone. In one embodiment, the mixed opioid partial includes unit dosage forms of a pharmaceutical composition agonist/antagonist is buprenorphine. adapted for the treatment of an addiction, wherein said unit 30 In one particular embodiment of a kit of the present inven dosage form comprises a peroxisome proliferator-activated tion, the addictive agent is nicotine and the additional thera receptor gamma (PPARY) agonistand an additional therapeu peutic agent is an antidepressant. In one embodiment, the tic agent, wherein said unit dosage form comprises the PPARY antidepressant is bupropion. agonist and the additional therapeutic agent in a combined In one particular embodiment of a kit of the present inven amount effective in the treatmentofan addiction, and wherein 35 tion, the addictive agent is a psychoStimulant and the addi each of the PPARY agonist and the additional therapeutic tional therapeutic agent is an antidepressant. In one embodi agent contribute to the effective treatment or prevention of the ment, the antidepressant is bupropion. addiction. In particular embodiments, the PPARYagonist is a In one particular embodiment of a kit of the present inven thiazolidinedione (TZD). In certain embodiments, the TZD is tion, the addictive agent comprises two or more addictive pioglitaZone, rosiglitaZone, ciglitaZone, troglitaZone, englita 40 agents and the additional therapeutic agent is an opioid Zone, rivoglitaZone or darglidaZone. In certain embodiments, antagonist or a mixed opioid partial agonist/antagonist. In one the additional therapeutic agent is an opioid antagonist, a embodiment, the opioid antagonist is naltrexone or mixed opioid partial agonist/antagonist, an antidepressant, an nalmefene. In one embodiment, the mixed opioid partial ago antiepileptic, an antiemetic, a corticotrophin-releasing fac nist/antagonist is buprenorphine. tor-1 (CRF-1) receptor antagonist, a selective serotonin-3 45 In a further embodiment, the present invention includes a (5-HT3) antagonist, a 5-HT2, antagonist, or a cannab kit comprising one or more unit dosage forms of a peroxisome inoid-1 (CB1) receptor antagonist. In one embodiment, the proliferator-activated receptor gamma (PPARY) agonist and opioidantagonist is naltrexone or nalmefene. In one embodi one or more unit dosage forms of nicotine. In one embodi ment, the antidepressant is fluoxetine, mirtazapine, or bupro ment, the one or more unit dosage forms of nicotine comprise pion. In one embodiment, the antiepileptic is selected from 50 two or more different amounts of nicotine. In one embodi the group consisting of topiramate, levetiracetam, and gaba ment, the PPARYagonist is a thiazolidinedione (TZD). In one pentin. In one embodiment, the CRF-1 receptor antagonist is embodiment, the TZD is pioglitaZone, rosiglitaZone, ciglita antalarmin. In one embodiment, the selective serotonin-3 Zone, troglitaZone, englitaZone, rivoglitaZone or darglida (5-HT3) antagonist is ondansetron. In one embodiment, the ZO. cannabinoid-1 (CB1) receptor antagonist is rimonabant or 55 In additional embodiment, the present invention includes a tanarabant. In one embodiment, the mixed opioid agonist/ method of preventing a Subject from becoming addicted, or antagonist is buprenorphine. reducing the likelihood that a subject will become addicted, to In one particular embodiment of a unit dosage form of the an addictive therapeutic agent, comprising providing to a present invention, the PPARY agonist is pioglitaZone and the Subject in need thereof an addictive therapeutic agent, and an additional therapeutic agent is naltrexone. 60 effective amount of a peroxisome proliferator-activated In another related embodiment, the present invention receptor gamma (PPARY agonist), wherein the effective includes a kit useful for the treatment or prevention of an amount of the PPARY agonist is an amount effective in pre addiction, comprising: a first container comprising a peroxi venting the Subject from becoming addicted, or reducing the Some proliferator-activated receptor gamma (PPARY) ago likelihood that the subject will become addicted, to the addic nist; and a second container comprising an additional thera 65 tive therapeutic agent. In particular embodiment, this method peutic agent, wherein each of the PPARY agonist and the further comprises providing to the Subject an additional thera additional therapeutic agent contribute to the effective treat peutic agent, wherein each of the PPARY agonist and the US 8,426,439 B2 11 12 additional therapeutic agent contribute to preventing the Sub alcohol intake measured at: 2 hours (FIG. 3A): 8 hours (FIG. ject from becoming addicted, or reducing the likelihood that 3B); and 24 hours (FIG. 3C) from the beginning of the dark the subject will become addicted, to the addictive therapeutic phase of the daily light/dark cycle. FIG. 3D shows daily food agent. In one embodiment, the addictive therapeutic agent is intake measured at 24 hour intervals. Significant difference an opioid agonist. from controls is indicated: *p-0.05. In certain embodiments of the methods of the present FIGS. 4A-4D are graphs demonstrating the effect of sub invention, the Subject is addicted to an addictive agent, or at chronic administration of 0.25 mg/kg of naltrexone (Ntx) risk for relapse use of an addictive agent. In various embodi alone or in combination with 10.0 or 30.0 mg/kg of pioglita ments, the pharmaceutical compositions, unit dosage forms, Zone (Pio 10 and Pio 30, respectively) on alcohol intake in and kits of the present invention are useful for the treatment or 10 msPrats. Controls were treated with drug vehicle (Veh-i-Veh). prevention of addiction to an addictive agent or relapse use of The values shown in FIGS. 4A-4C represent the meanisem of an addictive agent. In particular embodiments, the addictive daily alcohol intake measured at: 2 hours (FIG. 4A); 8 hours agent is alcohol, nicotine, marijuana, a marijuana derivative, (FIG. 4B); and 24 hours (FIG. 4C) from the beginning of the an opioid agonist, a benzodiazepine, a barbiturate, or a psy dark phase of the daily light/dark cycle. FIG. 4D shows daily chostimulant. In certain embodiments, the opioid agonist is 15 food intake measured at 24 hour intervals. Significant differ selected from the group consisting of morphine, methadone, ence from controls is indicated: *p-0.05. fentanyl, Sufentanil and heroin. In certain embodiments, the FIG. 5 is a bar graph depicting the effect ofpioglitazone on psychostimulant is cocaine, amphetamine oran amphetamine yohimbine-induced reinstatement of ethanol seeking behav derivative. In addition, the subject may be addicted to more iour. Compared to extinction (Ext), yohimbine elicited a sig than one addictive agent, and the pharmaceutical composi nificant reinstatement of responding that was markedly tions, unit dosage forms, and kits may be useful for treating or reduced by pre-treatment with 10.0 and 30.0 mg/kg of piogli preventing addiction or relapse use of more than one addictive taZone (Pio 10 and 30, respectively). Values represent the agent. mean (SEM) number of responses at the active lever. Sig In other embodiments of the present invention, the subject nificant difference from controls (pioglitazone vehicle: Veh) is addicted to an addictive or compulsive behavior or at risk 25 is indicated: **P<0.05. for relapse practice of an addictive or compulsive behaviour. FIG. 6 is a bar graph depicting the lack of effect of piogli In various embodiments, the pharmaceutical compositions, taZone on cue-induced reinstatement of ethanol seeking unit dosage forms, and kits of the present invention are useful behaviour. Values shown represent the mean (SEM) number for the treatment or prevention of addiction to an addictive or of responses at the active or inactive levers. Conditioning: compulsive behaviour or relapse use of an addictive or com 30 responses of the last 10% alcohol (filled circle) and water pulsive behaviour. In particular embodiments, the addictive (open circle) session of the discrimination phase. Extinction or compulsive behavior is pathological gambling, pathologi (EXT): responses during the last day of this phase. Reinstate cal overeating, pathological use of electronic devices, patho ment: responses in rats exposed to stimuli predictive of alco logical use of electronic video games, pathological use of hol (S"/CS") or water (S/CS) availability. Significant dif electronic communication devices, pathological use of cellu 35 ference from Ext is indicated: P-O.01. lar telephones, addiction to pornography, sex addiction, FIG. 7 is a graph depicting the effect of treatment with obsessive compulsive disorder, compulsive spending, anor ciglitazone 5.0 (Cig 5) or 20.0 mg/kg (Cig 20) or its vehicle exia, bulimia, intermittent explosive disorder, kleptomania, (Veh) on FR1 ethanol self-administration in Wistar rats. Each pyromania, trichotillomania, compulsive overexercising, and lever response resulted in the delivery of 0.1 ml of 10% compulsive overworking. In addition, the Subject may be 40 ethanol. Significant difference from controls (Veh) is indi addicted to more than one addictive or compulsive behaviour, cated: P-30.05. and the pharmaceutical compositions, unit dosage forms, and FIG. 8 is a graph the effect of administration of 7.5 or 15.0 kits may be useful for treating or preventing addiction or mg/kg of rosiglitaZone (Ros) on alcohol intake in msP rats. relapse use of more than one addictive or compulsive behav Controls were treated with the drug vehicle (Veh). Values 1OU. 45 represent the meantSem of alcohol intake (g/kg) at the indi cated time points. Significant difference from controls is indi BRIEF DESCRIPTION OF THE SEVERAL cated: **-0.01 and *p-0.05. VIEWS OF THE DRAWINGS FIGS. 9A and 9B are graphs depicting the effect of pre treatment with the PPARY antagonist GW9662 on pioglita FIG. 1 is a graph depicting the effect of acute administra 50 Zone induced reduction of ethanol drinking. FIG. 9A repre tion of 10.0 or 30.0 mg/kg of pioglitazone (Pio 10 and Pio 30, sents the effect of GW9662 (GW) given alone (1.0 and 5.0 respectively) on alcohol intake in Marchigian Sardinian alco mg/kg) on ethanol intake in msP rats. FIG.9B describes the hol-preferring (msP) rats. Controls were treated with vehicle effect of pre-treatment with GW9662 on animals injected only (Veh). Values represent the meant.semofalcohol intake. with 30 mg/kg pioglitazone (Pio) or its vehicle. The control Significant difference from controls is indicated: *p-0.05. 55 group received vehicles of both drugs (Veh-i-Veh). Values FIG. 2 is a graph depicting the effect of acute administra represent the meantsem of alcohol intake (g/kg). Significant tion of 0.25 mg/kg of naltrexone (Ntx) alone or in combina difference from controls is indicated: **p<0.01. tion with 10.0 or 30.0 mg/kg of pioglitazone (Pio 10 and Pio FIG.10 is a graph depicting the effect of pre-treatment with 30, respectively) on alcohol intake in msPrats. Controls were the PPARY antagonist GW9662 given ICV on pioglitazone treated with drugs vehicles (Veh-i-Veh). Values represent the 60 induced reduction of ethanol drinking. MsP rats received 5.0 mean Sem of alcohol intake. Significant difference from con ug?rat of GW9662 (GW) alone, 30 mg/kg of pioglitazone trols is indicated: **p<0.01 and *p-0.05. (Pio) alone or their combination. Control group received FIGS. 3A-3D are graphs demonstrating the effect of sub vehicles of both drugs (Veh-i-Veh). Values represent the chronic administration of 10.0 or 30.0 mg/kg of pioglitazone meantSem of alcohol intake (g/kg). Significant difference (Pio 10 and Pio 30, respectively) on alcohol intake in msP 65 from controls is indicated: *p-0.05 and **p<0.01. rats. Controls were treated with drug vehicle (Veh). The val FIG. 11 is a graph depicting the effect of naltrexone (Ntx) ues shown in FIGS. 3A-3C represent the meanisem of daily on yohimbine-induced reinstatement of alcohol seeking. US 8,426,439 B2 13 14 Compared to extinction (Ext) yohimbine elicited a significant FIG. 19 is a graph depicting the effect of administration of reinstatement of responding that was not modified by pre 10 mg/kg of pioglitaZone (Pio) alone or 1.0 mg/kg of treatment with 0.25 and 1.0 mg/kg of naltrexone. Values ondansetron alone or their combination on alcohol intake in represent the mean (SEM) number of responses at the active msP rats. Controls were treated with the drug vehicles (Veh-i- lever. Difference from controls (0.0) was not significant. Veh). Values represent the meantisem of alcohol intake FIG. 12 is a graph depicting the effect of naltrexone (Ntx) (g/kg). Significant difference from controls is on cue-induced reinstatement of alcohol seeking. Values rep indicated: **p-0.01 and *p-0.05. resent the mean (SEM) number of responses at the active FIG. 20 is a graph depicting the effect of administration of lever. Conditioning: responses of the last 10% alcohol (filled 10 mg/kg of pioglitaZone (Pio) alone or 15 mg/kg of anta circle) and water (open circle) session of the discrimination 10 larmin alone or their combination on alcohol intake in msP phase. Extinction (Ext): responses during the last day of this rats. Controls were treated with vehicles (Veh-i-Veh). Values phase. Reinstatement: responses in rats exposed to stimuli represent the meantsem of alcohol intake (g/kg). Significant predictive of alcohol (S"/CS") or water (S/CS) availability. difference from controls is indicated: *p-0.05 and **p<0.01. Treatment with 0.25 and 1.0 mg/kg of naltrexone signifi FIG. 21 is a graph depicting the effect of administration of cantly reduced cue-induced reinstatement of alcohol-seek 15 10 and 30 mg/kg of pioglitazone (Pio) on an alcohol with ing: **p-0.01. drawal score in Wistar rats. Controls received oral adminis FIGS. 13A and 13B are graphs depicting the effect of tration of alcohol vehicle. Values represent the meanisem of maltrexone (ntX) plus pioglitaZone (Pio) combination on: total withdrawal score. Significant difference from controls is yohimbine-induced reinstatement of alcohol seeking (FIG. indicated: **p<0.01. 13A) or cue-induced reinstatement of alcohol seeking (FIG. FIGS. 22A and 22B are graphs depicting the effect of 13B). Compared to extinction (Ext), yohimbine elicited a treatment with 10.0 or 30.0 mg/kg pioglitazone (10 or 30, significant reinstatement of responding. The combination of respectively) or its vehicle (veh) on FR5 cocaine self-admin Naltrexone (1.0 mg/kg) plus pioglitaZone (10 and 30 mg/kg) istration in Wistar rats. FIG. 22A shows the number of significantly inhibited yohimbine-induced reinstatement of rewards at the active lever, with each five lever response alcohol seeking (FIG. 13A). Treatment with 1.0 mg/kg of 25 resulting in the delivery of one reward (0.25 mg/0.1 ml of maltrexone in combination with Pioglitazone (10.0 and 30.0 cocaine). FIG.22B shows the number of responses at the left mg/kg) also significantly reduced cue-induced reinstatement inactive lever. Significant difference from controls (Veh) is of alcohol-seeking. Conditioning: responses of the last 10% indicated: **p<0.01. alcohol (filled circle) and water (open circle) session of the FIGS. 23A and 23B are graphs depicting the effect of discrimination phase. Extinction (Ext): responses during the 30 treatment with pioglitazone (30.0 mg/kg) or its vehicle (veh) last day of this phase. Reinstatement: responses in rats on FR5 nicotine self-administration in Wistar rats. FIG. 23A exposed to stimuli predictive of alcohol (S"/CS") or water shows the number of rewards at the active lever, with each five (S/CS) availability. Values represent the mean (SEM) lever response resulting in the delivery of 0.25 mg/0.03 ml of number of responses at the active lever. Significant difference nicotine. FIG. 23B shows the number of responses at the left from Ext is indicated: *P<0.05, **p-0.01. 35 inactive lever. Significant difference from controls (Veh) is FIG. 14 is a graph depicting the effect of administration of indicated: *p<0.05. 10 mg/kg of pioglitaZone (Pio) alone or 3 mg/kg of fluoxetine alone or their combination on alcohol intake in msP rats. DETAILED DESCRIPTION Controls were treated with the drug vehicles (Veh-i-Veh). Val ues represent the meantsem of alcohol intake (g/kg). Signifi 40 The present invention is based, in large part, upon the cant difference from controls is indicated: *p-0.05 and finding described herein that peroxisome proliferator-acti **p<0.01. vated receptor gamma (PPARY) agonists are useful in the FIG. 15 is a graph depicting the effect of administration of treatment and prevention of addictions and relapse use of an 10 mg/kg of pioglitaZone (Pio) alone or 5 mg/kg of mirtaza addictive agent or behaviour. Accordingly, the present inven pine alone or their combination on alcohol intake in msPrats. 45 tion provides methods and related compositions, formula Controls were treated with the drug vehicles (Veh-i-Veh). Val tions, unit dosage forms and kits for the treatment and pre ues represent the meantsem of alcohol intake (g/kg). Signifi vention of addiction and relapse use, which include one or cant difference from controls is indicated: *p-0.05. more PPARY agonists, alone or in combination with one or FIG. 16 is a graph depicting the effect of administration of more additional therapeutic agents in which each of the 10 mg/kg of pioglitaZone (Pio) alone or 30 mg/kg of topira 50 PPARY agonist and the additional therapeutic agent(s) con mate alone or their combination on alcohol intake in msPrats. tribute to the effective treatment or prevention of the addic Controls were treated with the drug vehicles (Veh-i-Veh). Val tion. ues represent the meantsem of alcohol intake (g/kg). Signifi As demonstrated in the accompanying Examples, a variety cant difference from controls is indicated: *p-0.05. of different thiazolidinediones (TZDs) were shown to reduce FIG. 17 is a graph depicting the effect of administration of 55 intake of an addictive agent in various models of addiction. 10 mg/kg of pioglitazone (Pio) alone or 100 mg/kg of leveti For example, each of the TZDS, pioglitaZone, ciglitaZone, and racetam (Leve) alone or their combination on alcohol intake rosiglitaZone, significantly reduced ethanol consumption in in msP rats. Controls were treated with vehicles alone (Veh-i- rat models of alcohol addiction (Examples 1,3,7, and 8). The Veh). Values represent the meantisem of alcohol intake effect was evident for both acute and subchronic administra (g/kg). Significant difference from controls is indicated: 60 tion of a TZD (Examples 1 and 2). In addition, TZDs were *p-0.05 and **p<0.01. shown to reduce cocaine use in a rat model of cocaine addic FIG. 18 is a graph depicting the effect of administration of tion (Example 23) and a rat model of nicotine addiction 10 mg/kg of pioglitaZone (Pio) alone or 30 mg/kg of gabap (Example 24). This effect of the PPARY agonists was shown entin alone or their combination on alcohol intake in msPrats. to be mediated by the activation of PPARY receptors using two Controls were treated with vehicles (Veh-i-Veh). Values rep 65 different PPARYagonists (Examples 9 and 10). In addition, an resent the meant sem of alcohol intake (g/kg). Significant observational study of human patients using pioglitaZone for difference from controls is indicated: **p-0.01 and *p<0.05. the treatment of diabetes confirmed that this PPARY agonist US 8,426,439 B2 15 16 was efficacious in reducing ethanol abuse (Example 22). PPARYagonists showed efficacy also in combination with These data establish that PPARYagonists may be used to treat opioid antagonists; co-administration of the two drugs and prevent addiction to a variety of different addictive resulted in additivity with regard to the effect on ethanol agents. drinking and expanded the efficacy of the opioid antagonist In addition, the accompanying Examples demonstrate that 5 on stress induced reinstatement. In a co-administration regi PPARYagonists used in combination with a variety of differ- men, it is of particular significance to note the neuroprotective ent therapeutic agents substantially reduced intake of an anticonvulsant and withdrawal-reducing effect of TDZs, addictive agent. For example, it is shown that acute or Sub- especially during the early treatment phase. In fact, opioid chronic treatment with the TZD, pioglitazone, enhanced the antagonists do not result in any amelioration of withdrawal inhibitor action of the opioidantagonist, naltrexone, on etha- 10 symptoms and this, in general, may contribute to the early nol intake (Examples 2 and 4). These data demonstrate that treatment drop out and low compliance often reported with the use of a PPARY agonist in combination with an opioid these drugs. antagonist would have increased, e.g., additive or synergistic, The ability of TDZs to normalize hepatic function may also efficacy in treating or preventing addiction. have positive consequences in exploitation of a combined In addition to reducing use of an addictive agent, PPARY 15 treatment approach. In fact, the clinical condition of alcoholic agonists were also able to reduce or prevent relapse use, or patients is, in general, compromised, especially during the reinstatement, of addictive agents. As described in Example early detoxification phase. Thus, rapid recovery and amelio 5, treatment with pioglitaZone significantly reduced stress- ration from a pathological state could improve treatment induced reinstatement of alcohol use. Interestingly, however, retention. it did not significantly reduce cue-induced reinstatement of 20 A. Methods of Treating and Preventing Addictions. Using alcohol use (Example 6). In contrast, the opioid antagonist, PPARY Agonist(s) maltrexone, reduced cue-induced reinstatement of alcohol Thus, the present invention includes methods of treating or use, but not stress-induced reinstatement of alcohol use (EX- preventing an addiction, comprising providing one or more amples 12 and 11). The data Support the concept that the PPARYagonists to a subject having an addiction or at risk for combination of a PPARY agonist and an opioid antagonist 25 developing an addiction. In various embodiments, the Subject would have an enhanced ability to prevent relapse use of an is addicted to an addictive agent or behaviour, including, but addictive agent, since Such a combination would prevent both not limited to, any of the addictive agents and behaviours stress-induced and cue-induced relapse use. In fact, treatment described herein. The subject may be physically or physi with the combination of the PPARYagonist, pioglitazone, and ologically dependent on the Substance or behaviour, the Sub the opioid antagonist, naltrexone, resulted in a significantly 30 ject may be psychologically dependent; or the Subject may be reduced reinstatement of both stress-induced and cue-in- both physically and psychologically dependent. The Subject duced alcohol use (Example 13). may be addicted to one or more than one addictive agent or PPARY agonists also worked synergistically with other behaviour. classes of therapeutic agents in reducing or preventing addic- As used herein, unless the context makes clear otherwise, tion and relapse use. For example, the TZD, pioglitazone, 35 “treat,” and similar word such as “treatment,” “treating etc., used in combination with a variety of different classes of is an approach for obtaining beneficial or desired results, antidepressants, including fluoxetine and mirtazapine, including and preferably clinical results. Treatment can worked synergistically in reducing ethanol consumption in an involve optionally either the reducing or amelioration of a animal model of ethanol addiction (Examples 14 and 15). disease or condition, (e.g., addiction, relapse use, with Anti-epileptics, including topiramate, levetiracetam, and 40 drawal), or the delaying of the progression of the disease or gabapentin, showed synergism in combination with a TZD in condition (e.g., addiction relapse use, withdrawal). reducing ethanol intake (Examples 16-18), and antiemetics, As used herein, unless the context makes clear otherwise, including the serotonin-3 (5-HT3) receptor selective antago- “prevent, and similar word such as “prevention.” “prevent nist, ondansetron, and the corticotrophin releasing factor 1 ing” etc., is an approach for preventing the onset or recurrence receptor selective antagonist, antalarmin, also showed syner- 45 of a disease or condition, (e.g., addiction, relapse use, with gism in combination with a TZD in reducing alcohol con- drawal) or preventing the occurrence or recurrence of the sumption (Examples 19 and 20). symptoms of a disease or condition, or optionally an approach Interestingly, the experiments described in the accompa- for delaying the onset or recurrence of a disease or condition nying Examples also showed that PPARY agonists signifi- or delaying the occurrence or recurrence of the symptoms of cantly reduced withdrawal symptoms in alcohol-addicted 50 a disease or condition. animals (Example 21). Generally, a subject is provided with an effective amount of In Summary, the present invention demonstrates that treat- a PPARY agonist. As used herein, an “effective amount’ or a ment with PPARYagonists represent a novel pharmacological “therapeutically effective amount of a Substance, e.g., a approach for the treatment and prevention of addiction, since PPARY agonist, is that amount sufficient to affect a desired it reduces addictive agent consumption and recidivism asso- 55 biological or psychological effect, Such as beneficial results, ciated to stress exposure. including clinical results. For example, in the context of treat In addition, considering that the physiopathology of addic- ing addiction using the methods of the present invention, an tion has features (i.e., drug craving, compulsive behaviour effective amount of a PPARYagonist is that amount sufficient triggered by drug desire, withdrawal, relapse behaviour, neu- to cause the Subject to reduce or discontinue use of an addic rological damages, cognitive impairment) common to all 60 tive agent. drugs of abuse it is reasonable to think that PPARY agonists According to certain embodiments of the present inven will be useful also for the treatment of dependence to other tion, a subject is provided with a PPARYagonist alone, while addictive agents or behaviours, including, e.g., opiates (mor- in other embodiments, a subject is provided with a PPARY phine, heroin methadone), psychoStimulants (cocaine, meth- agonist in combination with an additional therapeutic agent. amphetamine, and amphetamine related compounds in gen- 65 It is understood that the effective amount of either or both of eral), nicotine, gamma hydroxybutyrate (GHB), a PPARY agonist and an additional therapeutic agent may be phencyclidine, and phencyclidine derivatives, etc. different when either is provided alone than when provided in US 8,426,439 B2 17 18 combination. For example, when the PPARY agonist and the In particular embodiments, a Subject is considered at risk of additional therapeutic agent act synergistically, then a lower addiction or relapse to use of an addictive agent or practice of amount of the PPARY agonist, a lower amount of the addi an addictive behaviour when the subject has previously been tional therapeutic agent, or lower amounts of both the PPARY addicted to the same or a different addictive agent or addictive agonist or the additional therapeutic agent may be required to or compulsive behaviour. In certain embodiment, the subject achieve the same therapeutic effect that would be provided by is considered at risk of addiction or relapse to use of an either the PPARYagonist or the additional therapeutic agent addictive agent or practice of an addictive behaviour when the alone. In other embodiments, the same amount of the PPARY Subject is psychologically addicted to an addictive agent or agonist and the additional therapeutic agent are used to pro addictive or compulsive behaviour, even if the subject is no 10 longer physically addicted. vide an enhanced therapeutic effect relative to the therapeutic In certain embodiments, the subject is addicted to or at risk effect provided by either the PPARYagonist or the additional of becoming addicted to a therapeutic agent provided to the therapeutic agent alone. As another example, data in the patient to treat a disease or disorder, e.g., a pain medication. In Examples below indicate that patients addicted to alcohol and a related embodiment, the Subject may beat risk of abusing an treated with the PPARY agonist pioglitazone exhibit 15 addictive therapeutic agent, such as a pain medication. Abus decreased depression, and treatment of addicted patients with ing an addictive therapeutic agent, in certain embodiment, is a combination of a PPARY agonist and an antidepressant understood to indicate using the agent for a reason different agent in accordance with the present invention may provide than or in addition to its prescribed use. In such a situation, a an enhanced antidepressive therapeutic effect as part of the subject may be provided with both an addictive therapeutic treatment of the addictive disorder. agent and a PPARYagonist, alone or in combination with an The Subject may be any animal, including a mammal, and, additional therapeutic agent. For example, a Subject Suffering particularly, a human. from pain, or at risk of pain, may be provided with an opioid In one aspect of the invention, the subject is first deter agonist and a PPARY agonist or TZD, e.g., pioglitaZone, to mined or diagnosed to have an addiction, or to be at risk of both provide analgesia and prevent or treat addiction to the developing an addiction, by diagnostic testing, observation or 25 opioid agonist. Because PPARYagonists have been shown to analysis by a medical care provider. An effective amount of a reduce neuropatic pain and inflammatory responses (see, e.g., PPARY agonist, or an effective amount of a PPARY agonist Oliveira A. et al., Antinociceptive and antiedematogenic and one additional therapeutic agent, are then provided to the activities offenofibrate, an agonist of PPAR alpha, and piogli subject for treatment or prevention of the addiction. In taZone, an agonist of PPARgamma, Eur J. Pharmacol. 561 another aspect of the invention, the subject is first determined 30 (1-3):194-201 (2007)), the PPARy agonist may add to or or diagnosed to have an addiction, or to be at risk of devel enhance the analgesic affect of the opioid agonist. oping an addiction, by diagnostic testing, observation or In various embodiments, the subject is provided with the analysis by a medical care provider, but the Subject has not PPARY agonist at the same time that the Subject is using an been diagnosed or determined to have diabetes or other insu addictive agent, after the Subject has discontinued use of an lin disorder. An effective amount of a PPARY agonist, or an 35 addictive agent, or before the Subject begins using an addic effective amount of a PPARYagonistandone additional thera tive agent. peutic agent, are then provided to the Subject for treatment or 1. Addictive Agents prevention of the addiction. The dosage of the PPARYagonist, The term addiction is used to describe a recurring compul or the PPARY agonist and the one additional therapeutic sion by an individual to engage in some specific activity, agent, may be specifically determined by the medical practi 40 despite harmful consequences to the individuals health, tioner for treatment or prevention of the addiction rather than mental state or social life. The term is often reserved for drug for any other disorder or disease. addictions, but it is sometimes applied to other compulsions, In particular aspects, the subject is provided with a PPARY Such as problem gambling, and compulsive overeating. Fac agonist, alone or in combination with an additional therapeu tors that have been Suggested as causes of addiction include tic agent for the primary purpose of treating or preventing an 45 genetic, biological/pharmacological and Social factors. addiction. In related aspects of the methods of the present The medical community now makes a careful theoretical invention, the subject has not previously been provided with distinction between physical or physiological dependence a PPARY agonist for the treatment or prevention of any dis (characterized by Symptoms of withdrawal) and psychologi ease or disorder other than an addiction. In particular, in cal dependence (sometimes referred to simply as addiction). certain embodiments, the Subject has not previously been 50 Addiction is now narrowly defined as “uncontrolled, compul provided with a PPARY agonist for the treatment of insulin sive use.” If there is no harm being suffered by, or damage resistance or diabetes. In a further related embodiment, the done to, the patient or another party, then clinically it may be Subject has not been diagnosed with insulin resistance or considered compulsive, but to the definition of some it is not diabetes. categorized as “addiction'. In practice, the two kinds of In various embodiments of the present invention, the sub 55 addiction (physiological dependence and psychological ject may be provided with any PPARYagonist, including any dependence) are not always easy to distinguish. Addictions of the specific PPARYagonists described below. In particular often have both physical and psychological components. embodiments, the PPARY agonist is a TZD, including any of Physical dependence (or drug dependence) refers to a state the TZDs described below. In certain embodiments, the TZD resulting from habitual use of a drug, where negative physical is pioglitaZone, ciglitaZone, rosiglitaZone or trogalitaZone. 60 withdrawal symptoms result from abrupt discontinuation. In particular embodiments, the Subject is suffering from or Examples of addictive agents for which a user may develop a at risk for addiction to any physically addictive agent or physical dependence include nicotine, opioids, barbiturates, addictive or compulsive behaviour, including, e.g., any of benzodiazepines, alcohol, i.e., ethyl alcohol, GHB, and meth those described below. In particular embodiments, the subject aqualone. is addicted to alcohol, cocaine, nicotine, marijuana, an opiate 65 Commonly abused stimulants such as cocaine or amphet or other opioid agonist or methamphetamine or other psycho amine class drugs are not believed to cause significant physi stimulant, or phencyclidine and phencyclidine derivatives. cal dependence. However, their potential for extreme physi US 8,426,439 B2 19 20 ological addiction can compel the user to consume amounts phone, hydroxypethidine, isomethadone, ketobemidone, which become physically damaging, but life-threatening LMM, levorphanol, levophenacylmorphan, lofentanil, mep withdrawal effects have not been observed. eridine, metapon, metazocine, methadone, methadyl acetate, As used herein, addictive agents includes any and all agents metopon, morphine, myrophine, narceline, nicomorphine, to which a subject can become addicted, either physically or norlevorphanol, normethadone, normorphine, norpipanone, psychologically, or both. As noted above, addiction includes opium, oxycodone, oxymorphone, papaverine, phenadox addiction to chemical entities, such as drugs, e.g., ethyl alco one, phenomorphan, phenoperidine, piminodine, piritra hol, nicotine, or cocaine, as well as addiction to other behav mide, propheptazine, promedol, properidine, propoxyphene, iours, e.g., pathological gambling, pathological overeating, remifentanil, Sufentanil, thebaine, tildine, and tramadol. pathological use of electronic devices, e.g., BlackBerry(R), 10 pathological use of electronic video games, pathological use Naturally occurring opiates include codeine, morphine, of electronic communication devices, pathological use of noscapine, papaverine, and thebaine. Semi-synthetic opioids cellular telephones, addiction to pornography, sex addiction, include diacetylmorphine, hydrocodone, hydromorphone, obsessive compulsive disorder, compulsive spending, anor levorphanol, metapon, nalorphine, naloxone, naltrexone, exia, bulimia, intermittent explosive disorder, kleptomania, 15 oxycodone, oxymorphone, and tramadol. Synthetic opioids pyromania, trichotillomania, compulsive overexercising, and include ethoheptazine, fentanyl, levorphanol, meperidine, compulsive overworking. methadone, phenazocine, propoxyphene and Sufentanil. Addictive agents include addictive recreational drugs, as Three broad classifications of opiates are phenanthrenes, well as addictive medications. Examples of addictive agents phenylheptylamines, and phenylpiperidines. Examples of include, but are not limited to, alcohol, e.g., ethyl alcohol, phenanthrenes include codeine, etorpine, hydrocodone, gamma hydroxybutyrate (GHB), caffeine, nicotine, cannabis hydromorphone, morphine, oxycodone, and oxymorphone. (marijuana) and cannabis derivatives, opiates and other mor Examples of phenylheptylamines include dimeheptanol, phine-like opioid agonists Such as heroin, phencyclidine and dimenoxadol, dipipanone, isomethadone, methadone, meth phencyclidine-like compounds, sedative ipnotics such as adyl acetate, and propoxyphene. Examples of phenylpip benzodiazepines, methaqualone, mecloqualone, etaqualone 25 eridines include alfentanyl, alphaprodine, beta-promedol, and barbiturates and psychoStimulants such as cocaine, carfentanyl, fentanyl, lofentanil, meperidine, properidine, amphetamines and amphetamine-related drugs such as dex and Sufentanil. troamphetamine and methylamphetamine. Other examples Specific psychostimulants include, by way of example, include LSD, psilocybin, extasy and other hallucinogens. amphetamine, cocaine, dextroamphetamine, methamphet Examples of addictive medications include, e.g., benzodiaz 30 amine, pemoline, and methylenedioxymethamphetamine. epines, barbiturates, and pain medications including alfenta While a subject may be addicted to a single addictive agent nil, allylprodine, alphaprodine, anileridine benzylmorphine, or behaviour, frequently subject is addicted to two or more bezitramide, buprenorphine, butorphanol, clonitaZene, addictive agents or behaviours. Addiction to two or more codeine, cyclazocine, desomorphine, dextromoramide, dezo addictive agents or addictive behaviours is referred to as cine, diampromide, dihydrocodeine, dihydromorphine, 35 polyaddiction. dimenoxadol, dimepheptanol, dimethylthiambutene, diox 2. PPARY Agonists aphetylbutyrate, dipipanone, eptazocine, ethoheptazine, eth Peroxisome proliferator-activated receptors (PPARs) are ylmethylthiambutene, ethylmorphine, etonitaZene fentanyl. ligand-activated transcription factors of the nuclear hormone heroin, hydrocodone, hydromorphone, hydroxypethidine, receptor superfamily. At present three distinct PPAR iso isomethadone, ketobemidone, levallorphan, levorphanol, 40 forms, namely PPARC, PPARB/8 and PPARY, have been levophenacylmorphan, lofenitanil, meperidine, meptazinol, identified (Breidert et al., 2002; Feinstain et al. 2003). The metazocine, methadone, metopon, morphine, myrophine, PPARC. receptor isoform is highly expressed in the liver and nalbuphine, narceline, nicomorphine, norlevorphanol, kidney and it regulates fatty acid catabolism; the PPARB/ö is normethadone, nalorphine, normorphine, norpipanone, ubiquitously expressed and is involved in the regulation of opium, oxycodone, OXYCONTINR, oxymorphone, papav 45 different cellular processes including adipocytes, kerati ereturn, pentazocine, phenadoxone, phenomorphan, nocytes and oligodendrocytes differentiation. Finally, PPARY phenazocine, phenoperidine, piminodine, piritramide, proph receptors are predominantly expressed in adipose tissue and eptazine, promedol, properidine, propiram, propoxyphene macrophages, where they are involved in adipocyte differen Sufentanil, tramadol, tilidine, salts thereof, mixtures of any of tiation, regulation of Sugar and lipid homeostasis and control the foregoing, mixed L-agonists/antagonists, and the like. 50 of inflammatory responses (Heneka et al. 1999; Landreth and In certain embodiments, a subject may be addicted to an Heneka 2001; Harris and Phipps 2002). opioid agonist. The terms "opioid agonist,” “opioid’ and The endogenous ligands of PPAR receptors belong to vari “opiate' are used interchangably herein and are used to des ous classes of unsaturated fatty acid compounds that include ignate a group of drugs that are, to varying degrees, opium- or leukotrienes, retinoic acid metabolites and prostaglandins. morphine-like in their properties. Their main use is for pain 55 For example, the PPARY receptor is mainly located in the relief. These agents work by binding to opioid receptors, cytoplasmatic fraction and is activated by the 15-deossi which are found principally in the central nervous system and A'''-prostaglandin J. (Burstein 2005; Cernuda-Morollon, the gastrointestinal tract. Opiates are also addictive agents. et al., 2002). Opiates include alfentanil, allylprodine, alphaprodine, anile Recent studies have also shown that, in addition to various ridine, apomorphine, benzylmorphine, beta-hydroxy 3-meth 60 peripheral tissues, PPARB/ö and PPARY receptors are ylfentanyl, bezitramide, carfentanil, clonitaZene, codeine, expressed in neurons, and olygodendrocytes (but not in astro desomorphine, dextromoramide, diacetylmorphine (heroin), cytes) of the central nervous system (CNS). The exact role of diampromide, dihydrocodeine, dihydroetorphine, dihydro these receptors in the brain is not well understood yet (Kainu morphine, dimenoxadol, dimepheptanol, dimethylthiam et al. 1994). butene, dioxaphetylbutyrate, dipipanone, eptazocine, etho 65 It is known that activation of PPARY mediates neuropro heptazine, ethylmethylthiambutene, ethylmorphine, tective responses against excitotoxic process and inflamma etonitaZene, etorphine, fentanyl, hydrocodone, hydromor tory damages (Butcher et al. 2002). Activation of these recep US 8,426,439 B2 21 22 tors is also associated with improvement of cognitive addiction or relapse use of an addictive agent. In some performances, and has protective potential against epileptic embodiments, the additional agent is another anti-addiction insults (Yu et al. 2008) agent. In 1997 a new class of drugs, the thiazolidinediones The PPARY agonist and the additional therapeutic agent (TZDS), was developed in Japan, originally as anti-oxidants. may be administered at the same time (i.e., concurrently), or Certain of these compounds were then approved for the clini either may be administered before the other (i.e., sequen cal treatment of insulin resistance and type 2 diabetes. tially). In general, both the PPARYagonist and the additional At the molecular level, TDZs bind with high affinity and therapeutic agent are present in the Subject at the same time activate PPARY receptors; this has been proposed as the major for a duration of time and at levels sufficient to provide a mechanism through which these molecules exert their thera 10 therapeutic benefit to the subject, i.e., in the treatment or peutic effects. At present, two TDZ compounds are used preventing of an addiction or the prevention of a relapse use clinically to treat humans, pioglitaZone (ActoSR) and rosigli (or reinstatement) of an addictive agent or compulsive or taZone (Avandia(R). Pioglitazone and methods for synthesiz addictive behaviour. The PPARY agonist and the additional ing and formulating pioglitaZone and pioglitaZone composi therapeutic agent may be administered by the same or differ tions are further described in U.S. Pat. Nos. 4,687,777, 5,965, 15 ent routes of administration. Typically, the PPARY agonist 584 and 6,150.383, the disclosure of each of which is hereby and the additional therapeutic agent are each provided to a incorporated by reference. Other compounds (i.e., ciglita Subject according to a standard route of administration of a Zone, troglitaZone, aleglitazar, muraglitazar, tesaglitazar, and commercially available or other pharmaceutical composition. ragaglitazar, etc.) are under development. Suitable PPARY In one embodiment, the PPARY agonist and the additional agonists for use in the present invention include selective therapeutic agent are co-administered using a composition PPARY agonists such as ciglitaZone, troglitaZone, pioglita comprising both agents. Zone, rosiglitaZone, englitaZone, rivoglitaZone and darglida The additional therapeutic agent provided in combination ZO. with a PPARY agonist may be any therapeutic agent that An additional class of PPARYagonists are the dual-acting contributes to an aspect of the effective treatment or preven PPAR agonists. Dual-acting PPAR agonists are a novel group 25 tion of the addiction. For example, the additional therapeutic of compounds that activate nuclear transcription factors. By agent may be a drug used to treat an addiction or a drug used activating both PPARC. and PPARY receptors, they simulta to alleviate side-effects associated with physiological with neously reduce atherogenic triglycerides, raise cardioprotec drawal from an addictive agent. In addition, the additional tive HDI levels, and improve insulin resistance. Examples of therapeutic agent may be any drug that affects brain serotonin dual-acting PPAR agonists that may be suitable for use in the 30 neurotransmission, such as selective serotonin reuptake present invention include tesaglitazar, aleglitazar, muragli inhibitors (SSRIs), and tricyclic and tetracyclic serotonin and tazar, and ragaglitazar. norepinephrine reuptake inhibitors (SNRIs) as described Additional PPARY agonists that may be used according to below, and serotonin agonists such as Sumatriptan, ergono the present invention include, but are not limited to, those vine, dihydroergotamine and buspirone. In certain embodi described in the following patents and patent applications: 35 ments, the additional therapeutic agent is an opioid antago U.S. Pat. Nos. 6,294,580, 7,067,530, 6,582,738, 6,794,154, nist, including mixed opioid partial agonist/antagonists, an 4,812,570, 4,775,687, 4,725,610, 4,582,839, and 4,572,912: antidepressant, an antiepileptic, an antiemetic, a corticotro and U.S. Patent Application Publication Nos. US2002/ phin-releasing factor-1 (CRF-1) receptor antagonist, a selec 006942, US2007/0299047, US2004/0077525, and US2008/ tive serotonin-3 (5-HT3) antagonist, a 5-HT2, antagonist 0045580, the disclosures of which are hereby incorporated by 40 Such as mianserin, mirtazapine and ketanserin, or a cannab reference. Examples of dual PPARYagonists that may be used inoid-1 (CB1) receptor antagonist, including but not limited according to the present invention include, e.g., those to those therapeutic agents specifically described infra. described in U.S. Patent Application Nos. 2007/037882, In one embodiment, the addictive agent is alcohol and the US2006/0270722, US2006/0211749, US2006/0167045, and additional therapeutic agent is an opioidantagonist or a mixed US2005/0014833, the disclosures of which are hereby incor 45 opioidantagonist/partial agonist. In a particular embodiment, porated by reference. the opioid antagonist is naltrexone. In another embodiment, B. Methods of Treating and Preventing Addiction Using the mixed opioid partial agonist/antagonist is buprenorphine. PPARY Agonist(s) in Combination with Other Therapeutic In one embodiment, the addictive agent is alcohol, and the Agents additional therapeutic agent is topiramate or levetiracetam. As demonstrated in the accompanying Examples, PPARY 50 In one embodiment, the addictive agent is nicotine and the agonists may be effectively used in combination with one or additional therapeutic agent is an antidepressant. In a particu more additional therapeutic agents to treat or prevent addic lar embodiment, the antidepressant is bupropion. tion, including addiction to one or more of the addictive In one embodiment, the addictive agent is cocaine, and the agents described infra and compulsive or addictive behaviour. additional therapeutic agent is buprenorphine. Accordingly, the present invention includes methods of treat 55 In one embodiment, the addictive agent is a psychoStimu ing or preventing an addiction, comprising providing to a lant and the additional therapeutic agent is an antidepressant. subject addicted to an addictive agent one or more PPARY In a particular embodiment, the antidepressant is bupropion. agonist(s) and one or more additional therapeutic agent(s), in In one embodiment, the subject is addicted to two or more which each of the PPARYagonist(s) and the additional thera addictive agents and the additional therapeutic agent is an peutic agent(s) contribute to the effective treatment or pre 60 opioid antagonist or a mixed opioid partial agonist/antago vention of the addiction. In one embodiment, a Subject is nist. In a particular embodiment, the mixed opioid partial provided with or administered one PPARY agonist and one agonist/antagonist is buprenorphine. additional therapeutic agent. In another embodiment, a Sub In particular embodiments, a Subject is provided with a ject is addicted to two or more addictive agents. As demon combination of pioglitaZone and naltrexone; ciglitaZone and strated by the Examples below, the combination of a PPARY 65 maltrexone; rosiglitaZone and naltrexone; englitaZone and agonistand another therapeutic agent may have advantageous maltrexone; rivoglitaZone and naltrexone; darglidaZone and additive or synergistic efficacy in treating or preventing maltrexone; pioglitaZone and fluoxentine; ciglitaZone and flu US 8,426,439 B2 23 24 oxentine; rosiglitaZone and fluoxentine; englitaZone and flu tors. Opioid antagonists may antagonize central receptors, oxentine; rivoglitaZone and fluoxentine; darglidaZone and peripheral receptors or both. Naloxone and naltrexone are fluoxentine; pioglitaZone and mirtazapine; ciglitaZone and commonly used opioid antagonist drugs that are competitive mirtazapine; rosiglitaZone and mirtazapine; englitaZone and that bind to the opioid receptors with higher affinity than mirtazapine; rivoglitaZone and mirtazapine; darglidaZone agonists, but that do not activate the receptors. This effec and mirtazapine; pioglitaZone and topiramate; ciglitaZone tively blocks the receptor, preventing the body from respond and topiramate; rosiglitaZone and topiramate; englitaZone ing to opiates and endorphins. and topiramate; rivoglitaZone and topiramate; darglidaZone Many opioid antagonists are not pure antagonists but also and topiramate; pioglitaZone and levetiracetam; ciglitaZone produce Some weak opioid partial agonist effects, and can and levetiracetam; rosiglitaZone and levetiracetam; englita 10 Zone and levetiracetam; rivoglitaZone and levetiracetam; dar produce analgesic effects when administered in high doses to glidaZone and levetiracetam; pioglitaZone and gabapentin; opioid-naive individuals. Examples of Such compounds ciglitaZone and gabapentin; rosiglitaZone and gabapentin; include nalorphine, and levallorphan. However, the analgesic englitaZone and gabapentin: rivoglitaZone and gabapentin; effects from these drugs are limited and tend to be accompa darglidaZone and gabapentin; piolitaZone and ondansetron; 15 nied by dysphoria, most likely due to action at the kappa ciglitaZone and ondansetron; rosiglitaZone and ondansetron; opioid receptor. Since they induce opioid withdrawal effects englitaZone and ondansetron; rivoglitaZone and ondansetron; in people who are taking, or have previously used, opioid full darglidaZone and ondansetron; pioglitaZone and antalarmin; agonists, these drugs are considered to be antagonists. ciglitaZone and antalarmin; rosiglitaZone and antalarmin; Naloxone is one example of an opioid antagonist that has englitaZone and antalarmin: rivoglitaZone and antalarmin; no partial agonist effects. Instead, it is a weak inverse agonist darglidaZone and antalarmin. at mu opioid receptors, and is used for treating opioid over For treatment of alcohol addiction, combinations to be dose. administered in accordance with the present invention Specific examples of opioid antagonists that may be used include a PPARY agonist and an opioid agonist or a mixed according to the invention include alvimopan, binaltor opioid antagonist/partial antagonist, a PPARYagonist and an 25 phimine, buprenorphine, cyclazocine, cyclorphan, cypri antidepressant, a PPARYagonist and a CB1 receptor antago dime, dinicotinate, beta-funaltrexamine, levallorphan, meth nist/inverse agonist, a PPARY agonist and Varenicicline, a ylnaltrexone, nalbuphine, nalide, nalmefene, nalmexone, PPARY agonist and acamprosate, and a PPARY agonist and nalorphine, nalorphine dinicotinate, naloxone, naloxonazine, disulfiram. maltrendol, naltrexone, naltrindole, oxilorphan, and pentaZo For treatment of a psychostimulant addiction, combina 30 cine. tions to be administered in accordance with the present inven b. Antidepressents tion include, e.g., a PPARYagonistand an antidepressant or a Antidepressents are drugs used to treat depression. The PPARY agonist and a partial opioid agonist/antagonist, e.g., three neurotransmitters believed to be involved in depression buprenorphine. are serotonin, dopamine, and norepinephrine. Certain types For treatment of nicotine addiction, combinations to be 35 of antidepressants increase the levels of one or more of these administered in accordance with the present invention neurotransmitters in the brain by blocking their reabsorption. include, e.g., a PPARY agonist and an antidepressant, a Several different classes of antidepressants have been iden PPARY agonist and nicotine (as a replacement, in an oral, tified, including selective serotonin reuptake inhibitors (SS transcutaneous or other conventional formulation), a PPARY RIs), tricyclic and tetracyclic serotonin and norepinephrine agonist and an opioid antagonist, a PPARYagonistanda CB1 40 reuptake inhibitors (SNRIs), norepinephrine reuptake inhibi receptor antagonist/inverse agonist, and a PPARYagonistand tors (NRIs), norepinephrine and dopamine reuptake inhibi Varenicicline. tors (NDRIs), azaspirones, monoamine oxidase inhibitors For treatment of poly Substance addiction, combinations to (MAOIs), and atypical antidepressants. be administered in accordance with the present invention SSRIs include, e.g., cericlamine, citalopram, clomi include, e.g., a PPARY agonist and an opioid agonist or a 45 pramine, cyanodothiepin, dapoxetine, duloxetine, escitalo mixed opioid antagonist/partial antagonist. pram, femoxetine, fluoxetine, fluvoxamine, ifoxetine, imi For treatment of gambling addiction, combinations to be pramine, indalpine, indeloxazine, litoxetine, lofepramine, administered in accordance with the present invention mianserine, milnacipran, mirtazapine, nefazadone, nortrip include, e.g., a PPARY agonist and an antidepressant or a tyline, paroxetine, Sertraline, Sibutramine, tomoxetine, traZ PPARY agonist and an agent affecting dopamine neurotrans 50 odone, Venlafaxine, and Zimeldine. mission, e.g., a direct or indirect dopamine antagonist. Amitriptyline, amoxapine, butriptyline, clomipramine, The effective amount of either or both of a PPARYagonist demexiptiline, desipramine, dibenzepin, dimetacrine, dothi and an additional therapeutic agent may be reduced when epin, doxepin, imipramine, iprindole, lofepramine, mapro administered in combination that when either is provided tiline, melitracen, metapramine, mianserin, mirtazpine, alone. For example, when the PPARY agonist and the addi 55 nortriptyline, propizepine, protriptyline, quinupramine, set tional therapeutic agent act additively or synergistically, then iptiline, tianeptine, and trimipramine are all tricyclic and a lower amount of the PPARY agonist, a lower amount of the tetracyclic antidepressants. additional therapeutic agent, or lower amounts of both the SNRIs include, e.g., amoxapine, atomoxetine, bici fadine, PPARY agonist or the additional therapeutic agent may be desipramine, desvenlafaxine, dulloxetine, maprotiline, mil required to achieve the same therapeutic effect that would be 60 nacipran, nefazodone, reboxetine, Sibutramine, and Venlafax provided by either the PPARYagonist or the additional thera ine. peutic agent alone. Nisoxetine, nortriptyline, reboxetine, talsupram, and a. Opioid Antagonists tomoxetine are all examples of NRIs. An opioidantagonist acts on one or more opioid receptors. NDRIs include, e.g., bupropion, hydroxybupropion, and At least three types of opioid receptors, mu, kappa, and delta 65 tesofensine. opioid receptors, have been reported, and opioid antagonists AZaspirones include, e.g., buspirone, gepirone, ipsapirone, are generally classified by their effects on the opioid recep tandospirone, and tiaspirone. Buspirone is an anxiolytic (par US 8,426,439 B2 25 26 tial agonist at 5-HT1 autoreceptors) that may be provided 5-HT3 receptor antagonists include, e.g., alosetron, aza with an anti-depressant such as an SSRI. setron, bemesetron, cilansetron, dolasetron, granisetron, Specific MAOIs include, e.g., amiflamine, brofaromine, indisetron, itasetron, ondansetron, palonosetron, propisetron, clorgyline, alpha-ethyltryptamine, iproclozide, iproniazid, ramosetron, renZapride, tropisetron, and Zatosetron. isocarboxazid, mebanazine, moclobemide, nialamide, par Coritcosteroid anti-emetics include dexamethasone and gyline, phenelzine, pheniprazine, pirlindole, Safrazine, sel methylprednisolone. egiline, toloxatone, and tranlcypromine. Lymbic system inhibitors include alprazolam, lorazepam, Atypical antidepressants include, e.g., ameSergide, and midazolam. amineptine, benactyzine, bupropion, clozapine, fezolamine, Dopamine receptor antagonists include diphenhydramine, levoprotiline, lithium, medifoxamine, mianserin, minaprine, 10 olanzapine, oxafloZane, oxitriptan, rolipram, teniloxazine, dronabinol, haloperidol, metoclopramide, and prochlorpera tofenacin, traZodone, tryptophan, and viloxazine. Zine. c. Antiepileptics NK-1 receptor antagonists used as an anti-emetic include The anticonvulsants, also called anti-epileptic drugs aprepitant and morpholine, and an example of a GABA ago (AEDs) are a diverse group of drugs used in prevention of the 15 nist is propofol. occurrence of epileptic seizures and bipolar disorders. AEDs Thiethylperazine is a type of histamine receptor antago Suppress the rapid and excessive firing of neurons that begins nist. a seizure and/or prevents the spread of the seizure within the Cannabinoid receptor antagonists used as anti-emetics brain and offer protection against possible excitotoxic effects include dronabinol, nabilone, rimonabant, tanarabout, and that may result in brain damage. Many anticonvulsants block tetrahydrocannabinol. Sodium channels, calcium channels, AMPA receptors, or Examples of other anti-emetics include acetylleucine, NMDA receptors. monoethanolamine, aliZapride, benzquinamide, bietanau Anti-epileptic agents include, but are not limited to, ben tine, bromopride, buclizine, chlorpromazine, clebopride, Zodiazepines, barbituates, valproates, GABA agents, iminos cyclizine, dimenhydrinate, dipheniodol, domperidone, dran tilibenes, hydantoins, NMDA antagonists, sodium channel 25 isetron, meclizine, methalltal, metopimazine, oxypendyl. blockers and Succinamides. pipamazine, piprinhydrinate, Scopolamine, thioproperZaine, Benzodiazepines include, e.g., alprazolam, chlordiazep and trimethobenzamide. oxide, cholrazepate, clobazam, clonazepam, diazepam, e. Cannabinoid Receptor Antagonists halazapam, lorazepam, oxazepam, and prazepam. The cannabinoid receptors are a class of the G-protein Barbiturates used as anti-epileptics include, e.g., amobar 30 bital, mepobarbital, methylphenobarbital, pentobarbital, phe coupled receptor Superfamily. Their ligands are known as nobarbital, and primidone. cannabinoids. There are currently two known subtypes, CB1 Valproates used as anti-epileptics include, e.g., sodium which is expressed mainly in the brain, but also in the lungs, Valporate, valproic acid, valproate semisodium, and valpro liver, and kidney, and CB2, which is mainly expressed in the mide. 35 immune system and in hematopoietic cells. It is also believed Anti-epileptic GABA agents include, e.g., gabapentin, that there are novel cannabinoid receptors that is, non-CB1 losigamone, pregabalin, retigabine, rufinamide, and and non-CB2, which are expressed in endothelial cells and in vigabatrin. the CNS. Cannabinoid receptor antagonists may be selective Carbamazepine and oXcarbazepine are examples of imi for either the CB1 or CB2 receptor. The present invention nostilbenes. 40 contemplates the use of either or both CB1 and CB2 receptor Hydantoins include, e.g., fosphenytoin Sodium, mepheny antagonists. toin, and phenytoin Sodium. Addictive agents (e.g., alcohol, opiates, Delta(9)-tetrahy NMDA antagonists such as harkoseramide are used as drocannabinol (Delta(9)-THC) and psychostimulants, anti-epileptics. including nicotine) elicit a variety of chronically relapsing Sodium channel blockers such as lamotrigine are also anti 45 disorders by interacting with endogenous neural pathways in epileptic agents. the brain. In particular, they share the common property of Succinimides include, e.g., ethoSuximide, methSuximide, activating mesolimbic dopamine brain reward systems, and and phensuXimide. virtually all abused drugs elevate dopamine levels in the Other anti-epileptic drugs include acetazolamide, briver nucleus accumbens. Cannabinoid-1 (CB1) receptors are acetam, CBD cannabis derivative, clomthiazole edisilate, 50 expressed in this brain reward circuit and modulate the divalproex sodium, felbamate, isovaleramide, lacosamide, dopamine-releasing effects of Delta(9)-THC and nicotine. lamotrigine, levetiracetam, methaneSulphonamide, talam Rimonabant (SR141716), a CB1 receptor antagonist, panel, tiagabine, topiramate, Safinamide, seletracetam, Sore blocks both the dopamine-releasing and the discriminative tolide, Stiripentol, Sultiam, Valrocemide, and Zonisamide. and rewarding effects of Delta(9)-THC in animals. Although d. Antiemetics 55 CB1 receptor blockade is generally ineffective in reducing Anti-emetics are drugs effective against Vomiting and nau the self-administration of cocaine in rodents and primates, it sea. Anti-emetics are typically used to treat motion sickness reduces the reinstatement of extinguished cocaine-seeking and the side effects of opioid analgesics, general anaesthetics, behaviour produced by cocaine-associated conditioned and chemotherapy. stimuli and cocaine priming injections. Similarly, CB1 recep Classifications of anti-emetics include, e.g., 5-hydrox 60 tor blockade is effective in reducing nicotine-seeking behav ytryptamine 3 (5-HT3) receptorantagonists, histamine recep iour induced by re-exposure to nicotine-associated Stimuli. In tor antagonists, dopamine receptor antagonists, muscarinic human clinical trials, rimonabant was shown to block the receptorantagonists, acetylcholine receptorantagonists, can subjective effects of Delta(9)-THC in humans and prevents nabinoid receptor antagonists, limbic system inhibitors, relapse to Smoking in ex-Smokers. NK-1 receptor antagonists, corticosteroids, tachykinin 65 Other examples of cannabinoid receptor CB1 antagonists antagonists, GABA agonists, cannabinoids, benzodiaz include SR141716A (rimonabant), rosanabant, taranabant epines, anticholinergics, and Substance P inhibitors. and CP-94.5598. US 8,426,439 B2 27 28 C. Methods of Treating and Preventing Relapse the regulation of addictive behaviour associated with stress. Relapse use, or reinstatement, refers to the process of The CeA is rich in CRF immunoreactive cell bodies, termi returning to the use of alcohol or another addictive agent or nals, and receptors, and this neuronal CRF system has been the practice of an addictive behaviour after a period of absti implicated in the mediation of behavioural and emotional nence from, or limited or reduced use of an addictive agent or 5 responses to stressful stimuli (Dunn and Berridge 1990; Koob practice of an addictive behaviour. In certain situations, et al. 1994). For example, immobilization stress elevates relapse use of an addictive agent refers to the return to use of extracellular CRF levels in the CeA (Merlo Pich et al. 1995: an addictive agent by a subject who has undergone physical Merali et al. 1998) while intra-CeA injection of the CRF withdrawal from the addictive agent. Typically, the subject receptor antagonist, C-helical CRF9-41, reduces behavioural will have undergone physical withdrawal from the addictive 10 signs of anxiety produced by Social and environmental stres agent during a period of non-use or limited or reduced use of sors (Heinrichs etal. 1992; Swiergieletal. 1993). Anxiety and the addictive agent. In one embodiment, relapse use occurs in stress-like symptoms are central to drug and alcohol with a subject who has previously undergone a treatment regime drawal syndromes. Considering the evidence on a role of CRF with an effective amount of an anti-addiction agent to reduce neurons in the CeA in the regulation of emotional and anxio or eliminate use of an addictive agent, but who is no longer 15 genic effects of stress, it is likely that anxiogenic and stress using an effective amount of the anti-addiction agent. Anti like consequences of withdrawal from drugs of abuse may be addictive agents include any and all agents used to treat or mediated by the CRF system in the CeA as well. prevent addiction or withdrawal symptoms. Changes in the regulation of the activity of the CRF system Alcoholism, like many other addictions, is a chronic within the CeA may represent a critical neuroadaptive mecha relapsing disorder characterized by high recidivism rates. nism responsible for the development of dependence and Two major factors triggering relapse behaviour are stress and compulsive drug-seeking behaviour. environmental conditioning experiences (O'Brien et al. 1997: The data discussed above identify neuroadaptive changes Montietal. 1993: Shaham et al. 1995), which probably facili in brain circuitries and perturbations in stress systems as an tate relapse to alcohol-seeking via distinct brain mechanisms. important element in compulsive drug-seeking behaviour and For example, activation of the mesolimbic dopamine system 25 dependence. Another important factor in the long-lasting via an opioid-dependent mechanism (or via direct alterations addictive potential of drugs of abuse is the conditioning of in dopamine transmission in the basolateral nucleus of their rewarding actions with specific environmental stimuli. amygdala) seems to mediate the effect of drug-associated Environmental cues repeatedly associated with the subjective cues (Liu and Wiess 2002: Ciccocioppo et al. 2001), and, effects of drugs of abuse including alcohol can evoke drug extrahypothalamic CRF within the bed nucleus of the stria 30 craving (Childress et al. 1988; Ehrmanetal. 1992; Montietal. terminalis and median raphe nucleus is likely to mediate 1993; Pomerleau et al. 1983: Stormarket al. 1995) or elicit stress-induced reinstatement of drug-seeking behaviour (Erb automatic behavioural responses (Miller and Gold 1994; Tif et al 1998: Shaham et al. 1995; Le et al. 2000). fany and Carter 1998) that ultimately may lead to relapse. Several lines of evidence Suggest that molecular mecha Learned responses to drug-related Stimuli may, therefore, nisms underlying relapse to addiction are common to differ 35 contribute critically to the high rates of relapse associated ent classes of drugs of abuse. Drug craving and loss of control with cocaine and other drug addiction. over drug taking behaviour associated to relapse are under the Data from operant response-reinstatement models devel direct influence of stress and environmental conditioning oped to investigate drug-seeking behaviour associated with stimuli; the two major factors affecting resumption to drug exposure to drug-related environmental cues in rats indicate SC. 40 that discriminative stimuli predictive of cocaine (Weiss et al. Chronic drug abuse produces neuroadaptive changes not 2000), ethanol (Katneretal. 1999: Katner and Weiss 1999), or only within systems implicated in the acute reinforcing heroin (Gracy et al. 2000) availability reliably elicit strong effects of ethanol, but also within other motivational systems, recovery of extinguished drug-seeking behaviour in the notably brain stress-regulatory mechanisms. Stress has an absence of further drug availability. The response-reinstating established role in the initiation and maintenance of drug 45 effects of these stimuli show remarkable resistance to extinc abuse, and is a major determinant of relapse in abstinent tion with repeated exposure and, in the case of cocaine, can individuals (Brown et al. 1995; Marlatt et al. 1985; McKay et still be observed after several months of forced abstinence. al. 1995; Wallace 1989). The significance of stress in drug Additionally, in the case of ethanol, drug-seeking behaviour seeking behaviour has also been amply documented in the induced by ethanol-predictive discriminative stimuli was animal literature. Physical, Social, and emotional stress can 50 found to be enhanced in genetically alcohol-preferring Prats facilitate acquisition or increase self-administration of compared to Alcohol Nonpreferring (NP) and nonselected cocaine (Goeders et al. 1995; Haney et al. 1995; Ramsey and Wistar rats (Weiss and Ciccocioppo 1999). This observation VanRee 1993: Ahmed and Koob 1997), heroin, (Shaham and demonstrates that genetic predisposition toward heightened Stewart 2004), and ethanol (Nash et al. 1998; Mollenauer et ethanol intake is reflected also by a greater susceptibility to al. 1993; Blanchardet al. 1987: Higley et al. 1991)) in rodents 55 the motivating effects of ethanol cues (i.e., enhanced drug and nonhuman primates. Stressful stimuli have also been seeking under conditions where behaviour is not directly shown to elicit reinstatement of cocaine, heroin, and ethanol reinforced by ethanol itself). Together, these findings strongly seeking behaviour in drug-free animals following extinction Support the hypothesis that learned responses to drug-related (Ahmed and Koob 1997: Shaham 1993: Shaham and Stewart stimuli are a significant factor in long-lasting Vulnerability to 1995; Ie et al. 1998) and these findings provide experimental 60 relapse. Support for a role of stress in relapse. In humans, relapse risk involves multiple determinants that Traditionally, stress-related drug-seeking behaviour has are likely to interact. For example, exposure to drug cues may been thought to be mediated via activation of the hypotha augment Vulnerability to relapse imparted by protracted with lamic-pituitary-adrenal (HPA) axis. However, growing evi drawal symptoms resulting from neuroadaptive changes in dence Suggests that the non-neuroendocrine corticotropin 65 dependent individuals. Interactive effects exacerbating releasing factor (CRF) system in the central nucleus of the relapse risk may also exist between the motivating effects of amygdala (CeA) may play a significant independent role in stress and drug-related cues. Recent work addressing these US 8,426,439 B2 29 30 issues has confirmed that additive interactions between the concentration of the anti-addiction agent, and this lower response-reinstating effects of ethanol-associated cues and blood plasma concentration is not effective. stress can indeed be demonstrated, and that these effects are In certain embodiments of the methods of the present enhanced in rats with a history of ethanol dependence (Liu invention, the Subject has undergone a period of abstinence and Weiss 2000). from, or limited or reduced use of the addictive agent or In experimental laboratories, reinstatement of drug seek practice of the addictive or compulsive behaviour. This period ing is obtained with administration of the C-2 adrenoreceptor of abstinence or limited or reduced use may be, e.g., at least antagonistyohimbine, which, increasing brain noradrenaline 24 hours, at least 48 hours, at least 3 days, at least 5 days, at cell firing and release, acts as a pharmacological stressor. least one week, at least 2 weeks, at least 1 month, at least 2 Footshock stress and yohimbine-induced reinstatement of 10 months, at least 4 months, at least 6 months, at least 9 months, drug-seeking behaviours both represent valid experimental at least one year, at least 2 years, or at least 5 years. models to investigate stress-induced alcohol relapse (Lee et In another embodiment, the present invention includes a al. 2004; Le et al. 2000). method of treating or preventing relapse use of an addictive As shown in the accompanying Examples, PPARYagonists 15 agent, comprising providing a PPARY agonist and an opioid significantly reduce stress-induced relapse use of an addictive antagonist to a Subject who has undergone physiological agent (Example 5). In addition, in human patients, pioglita withdrawal from the addictive agent. Zone, a TZD, consistently reduced OCDS score (Example In a further embodiment, the present invention includes a 22). Obsession for alcohol and the urge to drink (which are method of treating or preventing relapse use of an addictive measured by OCDS scale) are the major predictors of relapse. agent, comprising providing a PPARY agonist and a CB1 These data indicate, therefore, that pioglitaZone has anti antagonist, e.g., disulfiram, topiramate, levetiracetam, SSRIs, relapse properties. orondansetron, to a subject who has undergone physiological Interestingly, the results showed that pioglitaZone did not withdrawal from the addictive agent. significantly prevent relapse elicited by conditioning factors. In particular embodiments, the relapse use is triggered by Interestingly, various reports have shown that the nonselec 25 stress, an environmental conditioning factor, or both. tive opiate receptor antagonist naltrexone reduces the urge to Examples of suitable PPARY agonists are TDZs, such as drink elicited by presentation of alcohol cues in human alco pioglitaZone, etc. One example of a Suitable opioid receptor holics (Monti et al. 1993) and decreases the efficacy of an antagonist is naltrexone. alcohol cue to reinstate extinguished responding at a previ While the methods of the present invention may be prac ously drug-paired lever in rats (Katner et al. 1999). However, 30 ticed in Subjects addicted to a single addictive agent, they may maltrexone does not reduce relapse behaviour elicited by also be used in subjects addicted to two or more addictive stress (Le A. D. Psychopharmacology 1998). agents. Similarly, while these methods may be used to prevent These findings suggest that the use of a combination of relapse use of the addictive agent from which the subject has pioglitaZone and naltrexone should result in a synergistic undergone withdrawal, they may also be adapted to prevent action to reduce relapse behaviour elicited by both stress and 35 relapse use or the commencement of use of an addictive agent conditioning factors. different than the one from which the subject has undergone Accordingly, the present invention provides treatment physiological withdrawal. methods and drug combinations that protect individuals from D. Methods of Reducing Withdrawal Symptoms and Treating the effects of more than a single environmental risk factor Depression/Anxiety (i.e., stress and environmental conditioning factors). 40 Withdrawal, also known as withdrawal/abstinence syn In one embodiment, the present invention provides a drome, refers to the characteristic signs and symptoms that method of treating or preventing stress-induced relapse use of appear when a drug or addictive agent that causes physical an addictive agent, comprising providing a PPARYagonist to dependence is regularly used for a long time and then Sud a Subject who has undergone physiological withdrawal from denly discontinued or decreased in dosage. Withdrawal an addictive agent. 45 symptoms can vary significantly among individuals, but there In a related embodiment, the invention includes a method are some commonalities. Brain dysfunction associated with of treating or preventing relapse use of an addictive agent or drawal is often characterized by depression, anxiety and crav practice of an addictive or compulsive behaviour, comprising ing, and, if extreme, can help drive the individual to continue providing an effective amount of a peroxisone proliferator the drug despite significant harm—the definition of addic activated receptor gamma (PPARY agonist) to a subject who 50 tion—or even to Suicide. previously reduced or eliminated use of an addictive agent or Increased heart rate and/or blood pressure, Sweating, and practice of an addictive or compulsive behaviour in response tremors are common signs of withdrawal. More serious to exposure to an effective amount of another anti-addiction symptoms such as confusion, seizures, and visual hallucina treatment, wherein the Subject is no longer exposed to an tions indicate a serious emergency and the need for immedi effective amount of the anti-addiction treatment. The anti 55 ate medical care. Alcohol, opiates, benzodiazepines, and bar addiction treatment may be an anti-addiction drug or may be biturates are the only commonly abused substances that can a non-pharmacologic therapy Such as counseling, psycho be fatal in withdrawal. Abrupt withdrawal from other drugs, therapy or hypnosis therapy. The relapse use may be triggered Such as nicotine or psychostimulants, can exaggerate mild to by stress. moderate neurotoxic side effects due to hyperthermia and In certain embodiments, the Subject is no longer exposed to 60 generation of free radicals, but life-threatening complications an effective amount of an anti-addiction agent because the are very rare. subject has become tolerant to the agent, such that the blood As demonstrated in the accompanying Examples, PPARY plasma concentration of the anti-addiction agent that was agonists reduce withdrawal symptoms (Example 21). In addi previously effective in treating the addiction is no longer tion, they decreased anxiety and depression, which is also effective. In other embodiments, the subject is no longer 65 associated withdrawal (Example 22). These data demonstrate exposed to an effective amount of an anti-addiction agent that PPARY agonists may be successfully used to reduce because the Subject is now exposed to a lower blood plasma withdrawal symptoms, including depression and anxiety, US 8,426,439 B2 31 32 thus making withdrawal easier for Subjects and encouraging gabapentin; rosiglitaZone and gabapentin; englitaZone and them to complete the withdrawal process. gabapentin: rivoglitaZone and gabapentin; darglidaZone and The present invention includes a method of reducing one or gabapentin; piolitaZone and ondansetron; ciglitaZone and more withdrawal symptoms associated with reduced or dis ondansetron; rosiglitaZone and ondansetron; englitaZone and continued use of an addictive agent, comprising providing an ondansetron; rivoglitaZone and ondansetron; darglidaZone effective amount of a peroxisome proliferator-activated and ondansetron; pioglitaZone and antalarmin; ciglitaZone receptor gamma (PPARY) agonist to a subject undergoing and antalarmin; rosiglitaZone and antalarmin; englitaZone physiological withdrawal from an addictive agent. and antalarmin; rivoglitaZone and antalarmin; darglidaZone The PPARY agonist may be provided to the subject before and antalarmin. the subject begins withdrawal and/or during the withdrawal 10 The compositions of the present invention may be admin process. In a related method, a Subject is provided with a istered to a subject as a pharmaceutical composition or for PPARYagonist over a period of time during which the subject mulation. In particular embodiments, pharmaceutical com uses a reduced amount of an addictive agent. In one embodi positions of the present invention may be in any form which ment, the Subject uses a step-wise reduced amount of an allows for the composition to be administered to a subject. For addictive agent at the same time as a PPARY agonist, until 15 example, the composition may be in the form of a solid, liquid physical withdrawal is completed. The subject may then dis or gas (aerosol). Typical routes of administration include, continue use of the PPARY agonist or continue use of the without limitation, oral, topical, parenteral, Sublingual, rec PPARY agonist to prevent relapse. In one particular embodi tal, vaginal, and intranasal. The term parenteral as used herein ment, the addictive agent is nicotine, and the Subject reduces includes Subcutaneous injections, intravenous, intramuscu use of nicotine over a period of time during which the subject lar, epidural, intrasternal injection or infusion techniques. is provided with a PPARYagonist, Such as a TZD, e.g., piogli Pharmaceutical compositions used according to the taZone, alone or in combination with another therapeutic present invention comprise a PPARY agonist, another thera agent. peutic agent, and a pharmaceutically acceptable diluent, E. Pharmaceutical Compositions, Routes of Administration, excipient, or carrier. “Pharmaceutically acceptable carriers' Unit Dosage Forms, Kits, 25 for therapeutic use are well known in the pharmaceutical art, The present invention has established the efficacy of using and are described, for example, in Remingtons Pharmaceu combinations of a PPARYagonist, e.g., a TZDSuch as piogli tical Sciences, Mack Publishing Co. (A. R. Gennaro edit. taZone, in combination with one or more additional therapeu 1985). For example, sterile saline and phosphate-buffered tic agents, such as opioid antagonists, antidepressants, anti saline at physiological pH may be used. Preservatives, stabi epileptics, antiemetics, and CB1 receptor antagonists. Thus, 30 lizers, dyes and even flavoring agents may be provided in the the present invention further includes compositions compris pharmaceutical composition. For example, sodium benzoate, ing one or more PPARYagonists and one or more additional sorbic acid and esters of p-hydroxybenzoic acid may be added therapeutic agents, such as opioid antagonists, mixed opioid as preservatives. Id. at 1449. In addition, antioxidants and antagonists/partial agonist, antidepressants, antiepileptics, Suspending agents may be used. Id. antiemetics, CRF1 receptor antagonists and CB1 receptor 35 Pharmaceutical compositions of the invention are gener antagonists. ally formulated so as to allow the active ingredients contained In particular embodiments, the composition comprises one therein to be bioavailable upon administration of the compo PPARY agonist and one additional therapeutic agent. In one sition to a subject. Compositions that will be administered to particular embodiment, a composition comprises a TZD and a Subject may take the form of one or more dosage units, one additional therapeutic agent. In certain embodiments, the 40 where for example, a tablet, capsule or cachet may be a single additional therapeutic agent is an opioidantagonist or a mixed dosage unit, and a container comprising a combination of opioid antagonist/partial agonist. In one embodiment, the agents according to the present invention in aerosol form may opioid antagonist is naltrexone. In another embodiment, the hold a plurality of dosage units. mixed opioid partial agonist/antagonist is buprenorphine. In In particular embodiments, the composition comprising a certain embodiments, the additional therapeutic agent is an 45 PPARYagonist and another therapeutic agent is administered antidepressant. In a particular embodiment, the antidepres in one or more doses of a tablet formulation, typically for oral sant is bupropion. In certain embodiments, the additional administration. The tablet formulation may be, e.g., an imme therapeutic agent is an antiepileptic, an antiemetic, or an diate release formulation, a controlled release formulation, or opioid antagonist or a mixed opioid partial agonist/antago an extended release formulation. In one embodiment, a tablet nist. 50 formulation comprises an effective amount of a composition In various embodiments, the composition comprises: comprising a PPARYagonistand another therapeutic agent. In pioglitaZone and naltrexone; ciglitaZone and naltrexone; particular embodiments, a tablet comprises about 1, 5, 10, 20, rosiglitaZone and naltrexone; englitaZone and naltrexone; 30, 50 100, 150,200,250, or 300 mg of a PPARYagonist, such rivoglitaZone and naltrexone; darglidaZone and naltrexone; as pioglitazone, and about 1, 5, 10, 20, 30, 50 100, 150, 200, pioglitaZone and fluoxentine; ciglitaZone and fluoxentine; 55 250, or 300 mg of another therapeutic agent. rosiglitaZone and fluoxentine; englitaZone and fluoxentine; The present invention further includes unit dosage forms of rivoglitaZone and fluoxentine; darglidaZone and fluoxentine; pharmaceutical compositions comprising a PPARY agonist pioglitaZone and mirtazapine; ciglitaZone and mirtazapine; and another therapeutic agent. Each unit dosage form com rosiglitaZone and mirtazapine; englitaZone and mirtazapine; prises a therapeutically effective amount of a pharmaceutical rivoglitaZone and mirtazapine; darglidaZone and mirtazap 60 composition of the present invention, when used in the rec ine; pioglitaZone and topiramate; ciglitaZone and topiramate; ommended amount. For example, a unit dosage form may rosiglitaZone and topiramate; englitaZone and topiramate; include a therapeutically effective amount in a single tablet, rivoglitaZone and topiramate; darglidaZone and topiramate; or a unit dosage form may include a therapeutically effective pioglitaZone and levetiracetam; ciglitaZone and levetirac amount in two or more tablets, such that the prescribed etam; rosiglitaZone and levetiracetam; englitaZone and leve 65 amount comprises a therapeutically effective amount. tiracetam; rivoglitaZone and levetiracetam; darglidaZone and A number of the PPARY agonists and other therapeutic levetiracetam; pioglitaZone and gabapentin; ciglitaZone and agents described herein are approved for human use at par US 8,426,439 B2 33 34 ticular dosages. The present invention contemplates using dosage forms may be provided to a Subject in a therapeuti these agents at their approved dosages or at other effective cally effective manner. In particular embodiments, a kitcom dosages. Since the combination of a PPARY agonist and prises unit dosage forms of pioglitaZone and naltrexone; another therapeutic agent has been demonstrated to have syn ciglitaZone and naltrexone; rosiglitaZone and naltrexone; ergistic efficacy, it is understood that effective amounts of one 5 englitaZone and naltrexone; rivoglitaZone and naltrexone; or both agents may be reduced when provided together, as darglidaZone and naltrexone; pioglitaZone and fluoxentine; compare to the effective amount of each when provided ciglitaZone and fluoxentine; rosiglitaZone and fluoxentine; alone. In particular embodiments, a PPARY agonist is pro englitaZone and fluoxentine; rivoglitaZone and fluoxentine; vided to a subject in an amount in the range of 0.1-1000 darglidaZone and fluoxentine; pioglitaZone and mirtazapine; mg/day, 1-1000 mg/day, 10-100 mg/day, or 25-50 mg/day. In 10 ciglitaZone and mirtazapine; rosiglitaZone and mirtazapine; one embodiment, pioglitaZone is provided to a patient at englitaZone and mirtazapine; rivoglitaZone and mirtazapine; about 30 mg/day. darglidaZone and mirtazapine; pioglitaZone and topiramate; Table 1 lists representative agents used in the present inven ciglitaZone and topiramate; rosiglitaZone and topiramate; tion and provides the daily dosages at which these agents are englitaZone and topiramate; rivoglitaZone and topiramate; conventially administered to adults for other indications, 15 darglidaZone and topiramate; pioglitaZone and levetiracetam; which dosages are believed to be useful for administration in ciglitaZone and levetiracetam; rosiglitaZone and levetirac accordance with the methods of the present invention in the etam; englitaZone and levetiracetam; rivoglitaZone and leve treatment or prevention of addiction and relapse use or prac tiracetam; darglidaZone and levetiracetam; pioglitaZone and tice. Dosages listed are oral unless otherwise indicated. It is gabapentin; ciglitaZone and gabapentin; rosiglitaZone and believed that the dosages of these agents may be reduced gabapentin; englitaZone and gabapentin: rivoglitaZone and when delivered in combinations of a PPARY agonist and an gabapentin; darglidaZone and gabapentin; piolitaZone and additional therapeutic agent in accordance with the present ondansetron; ciglitaZone and ondansetron; rosiglitaZone and invention for the treatment or prevention of addiction or for ondansetron; englitaZone and ondansetron; rivoglitaZone and the treatment or prevention of relapse use. These reductions ondansetron; darglidaZone and ondansetron; pioglitaZone may be up to 10% of conventional dosages, or up to 20% of 25 and antalarmin; ciglitaZone and antalarmin; rosiglitaZone and conventional dosages, or up to one third of conventional antalarmin; englitaZone and antalarmin: rivoglitaZone and dosages, up to one half of conventional dosages or up to two antalarmin; darglidaZone and antalarmin. thirds of conventional dosages. For example, pioglitaZone is In one embodiment, the present invention includes a kit most commonly dosed at 30 mg per day for treatment of comprising unit dosage forms of a PPARY agonist and unit diabetes, which dosage was found to be effective for the 30 dosage forms of nicotine. In one embodiment, the unit dosage treatment of alcoholism (Example 22). When combined with forms of nicotine comprise a plurality of different unit dosage 50 mg/day naltrexone in accordance with the present inven forms of nicotine, wherein the different dosage forms of tion for treatment of addiction, it is believed therapeutic effect nicotine represent decreasing amount that may be taken one may be seen at 10-15 mg per day of pioglitaZone. after the other over a period of time, so as to overcome 35 addiction and effectuate withdrawal from the nicotine. The TABLE 1. unit dosage forms of nicotine may be present, e.g., in the form of a skin patch, gum, or a lozenge. Therapeutic Exemplary Dosage Agent Applied as Single Agent EXAMPLES pioglitaZone 15-45 mg 40 rosiglitaZone 2-8 mg The following examples describe a number of studies per troglitaZone 200-600 mg rimonabant 10-20 mg formed to demonstrate the effect of various PPARY agonists buprenorphine 0.3 mg (IV or IM) for treating addiction and preventing relapse for a variety of 12-16 mg (Sublingual) addictive agents. Certain examples describe studies demon maltrexone 25-50 mg 45 strating the effect of PPARY agonists used in combination fluoxetine 20-80 mg mirtazipine 15-45 mg with other therapeutic agents to treat alcohol addiction. These topiramate 400 mg studies were performed using well-validated laboratory ani levetiracetam 1,000-6,000 mg mal models for alcohol abuse and cocaine abuse. gabapentin 900-1,800 mg Most of the studies described in Examples 1-21 were con Ondansetron 8-24 mg 50 ducted using male, genetically selected alcohol-preferring bupropion 200-400 mg rats, referred to as Marchigian Sardinian alcohol-preferring (msP) rats. These animals were bred at the Department of In one particular embodiment, a unit dosage form of a Pharmacological Sciences and Experimental Medicine of the pharmaceutical composition of the present invention com University of Camerino (Marche, Italy) for 60 generations prises about 30 mg of pioglitaZone and about 50 mg of naltr 55 from Sardinian alcohol-preferring rats of the 13" generation, exone. This unit dosage form may consist of one or more provided by the Department of Neurosciences of the Univer tablets. sity of Cagliari, Italy. At the time of the experiments, their Certain combinations of PPARY agonists and other thera body weight ranged between 300 and 350 g. They were peutic agents may not be readily adaptable to coformulation. housed in a room on a reverse 12-hourlight/dark cycle (lights For example, one of the agents may be more amenable to 60 off at 9:00 a.m.), temperature of 20-22°C. and humidity of intravenous administration, while another of the agents may 45-55%. The rats were offered free access to tap water and be more amenable to oral administration. Or, the serum half food pellets (4RF18, Mucedola, Settimo Milanese, Italy). In life of the two agents may be such that one must be adminis the operant self-administration experiments, male heteroge tered more frequently than the other. Accordingly, the present neous Wistar rats (Charles River, Germany) were used. invention contemplates kits comprising one or more unit dos 65 Experiments were performed at 9:30 a.m., which is the age forms of a PPARY agonist and one or more unit dosage beginning of the dark phase of the light/dark cycle. Separate forms of another therapeutic agent, Such that the two unit groups of animals were used in each experiment. All proce US 8,426,439 B2 35 36 dures were conducted in adherence to the European Commu For the conditioning phase, at the completion of the fading nity Council Directive for Care and Use of Laboratory Ani procedure (see above), in 30 min daily sessions, animals were mals and the National Institutes of Health Guide for the Care trained to discriminate between 10% alcohol and water. and Use of Laboratory Animals. Beginning with self-administration training at the 10% alco PioglitaZone, rosiglitaZone, fluoxetine, mirtazapine, topi hol concentration, discriminative stimuli (SD) predictive of ramate, gabapentine, ondansetrone, and levetiracetam was alcohol versus water availability were presented during the purchased from commercial Sources. Yohimbine and ciglita alcohol and water self-administration sessions, respectively. Zone were purchased from SIGMA SRL (Mi, Italy). Naltrex The discriminative stimulus for alcohol consisted of the one and GW9662 were obtained from TOCRIS (U.K). odour of an orange extract (S) whereas water availability Prior to administration, pioglitaZone was suspended in dis 10 (i.e. no reward) was signalled by an anise extract (ST). The tilled water, and the resulting Suspension was maintained olfactory stimuli were generated by depositing six to eight under constant agitation until administration. The drug was drops of the respective extract into the bedding of the operant given orally (OS) via gavage procedure in a Volume of 1.0 chamber. In addition, each lever-press resulting in delivery of ml/kg. Yohimbine was dissolved in distilled water and was alcohol was paired with illumination of the chamber's house administered intraperitoneally (IP) in a volume of 1.0 ml/kg. 15 light for 5 sec (CS). The corresponding cue during water Naltrexone hydrochloride was dissolved in distilled water sessions was a 5 second tone (70 dB) (CST). Concurrently and administered IP in a volume of 1.0 ml/kg. Rosiglitazone, with the presentation of these stimuli, a 5 sec. time-out period fluoxetine, mirtazapine, topiramate, gabapentin and leveti was in effect, during which responses were recorded but not racetam were Suspended in distilled water, and resulting Sus reinforced. The olfactory stimuli serving as S" or S for pensions were maintained under constant agitation until alcohol availability were introduced one minute before exten administration. These drugs were given orally (OS) via gav sion of the levers and remained present throughout the age procedure in a Volume of 1.0 ml/kg. Yohimbina was 30-min. Sessions. The bedding of the chamber was changed dissolved in distilled water and was administered intraperito and bedding trays were cleaned between sessions. During the neally (IP) in a volume of 1.0 ml/kg. GW9662 was prepared first three days of the conditioning phase, the rats were given in 5% DMSO and 5% TWIN 80 and was given either IP (1 25 alcohol sessions only. Subsequently, alcohol and water ses ml/kg) or intacerebroventricularly (ICV. 1 ul/rat). Antalarmin sions were conducted in random order across training days, was prepared in 10% TWIN 80 and was given IP (1 ml/kg). with the constraint that all rats received a total of 10 alcohol Ondansetron was prepared in aqueous Solution and was given and 10 water sessions. IP (1 ml/kg). For the extinction phase, after the last conditioning day, At the beginning of the experiments, msPrats were allowed 30 rats were subjected to 30-min extinction sessions for 15 con free choice between water and 10% (v/v) alcohol 24 h/day for secutive days. During this phase, sessions began by extension at least 15 days. The fluids were offered in graduated drinking of the levers without presentation of the SD. Responses at the tubes equipped with metallic drinking spouts. The position lever activated the delivery mechanism but did not result in (to the right or left) of alcohol and water drinking tubes was the delivery of liquids or the presentation of the response changed daily to avoid the development of side preference. 35 contingent cues (house light or tone). Water and food were available ad libitum, while alcohol The reinstatement testing phase began the day after the last access was either restricted to 2 hours/day (Examples 1 and 2) extinction session. This test lasted 30-min under conditions or was available 24 hours/day (Examples 3 and 4). Alcohol, identical to those during the conditioning phase, except that water and food intakes were measured. alcohol and water were not made available. Sessions were Training and testing were conducted in standard operant 40 initiated by the extension of both levers and presentation of chambers (Med Associate) located in Sound-attenuating, ven either the alcohol S" or water Spaired stimuli. The respec tilated environmental cubicles. Each chamber was equipped tive SD remained present during the entire session and with a drinking reservoir (volume capacity: 0.30 ml) posi responses at the previously active lever were followed by tioned 4 cm above the grid floor in the centre of the front panel activation of delivery mechanism and a 5-sec presentation of of the chamber, and two retractable levers located 3 cm to the 45 CS" in the S" condition or the CS (tone) in the S condition. right or to the left of the drinking receptacle. Auditory and Rats were tested under the S/CS condition on day 1 and visual stimuli were presented via a speaker and a light located under S"/CS" condition on day 2. on the front panel. A microcomputer controlled the delivery Stress-induced reinstatement of alcohol-seeking experi of fluids, presentation of auditory and visual stimuli, and mental procedures consisted of three phases: (1) training recording of the behavioural data. 50 phase; (2) extinction phase; and (3) reinstatement phase, as Rats were trained to self-administer 10% alcohol (v/v) in described below. 30-min. daily sessions on a fixed-ratio 1 schedule of rein For the training phase, after completion of the fading pro forcement, in which each response resulted in delivery of 0.1 cedure, msP rats were trained to self-administer 10% (v/v) ml of fluid as previously described (Economidou et al. 2006). alcohol for 15 days in 30-min daily sessions under a FR1 For the first 3 days, rats were allowed to lever-press for a 0.2% 55 schedule of reinforcement. During the infusion, a stimulus (w/v) Saccharin solution, and then trained to self-administer house light was turned on for 5s (time out; TO). Lever presses 10% alcohol by fading the saccharine (Weiss et al. 1993). during the TO period were counted, but did not lead to further During the first 6 days of training, rats were allowed to lever infusions. press for a 5.0% (v/v) alcohol solution containing 0.2% (w/v) For the extinction phase, after the last alcohol self-admin saccharin. Starting on day 7, the concentration of alcohol was 60 istration session, animals were Subjected to 30-min extinction gradually increased from 5.0% to 8.0% and finally to 10.0% sessions for 15 consecutive days. Responses at the lever acti (w/v), while the concentration of Saccharin was correspond vated the delivery mechanism but did not result in the delivery ingly decreased to 0%. of alcohol. Cue-induced reinstatement of alcohol-seeking behaviour For the reinstatement phase, the day after the last extinction experimental procedures consisted of three phases: (1) con 65 session, rats were injected with yohimbine (1.25 mg/kg) and ditioning phase; (2) extinction phase; and (3) reinstatement after 30 minutes were placed in the operant chamber and lever phase, as described below. presses was monitored for 30 min. It is known that adminis US 8,426,439 B2 37 38 tration of the C-2 adrenoreceptor antagonist yohimbine, the inhibitory action of opioid antagonists on ethanol intake. increasing brain noradrenaline cell firing and release, acts as The dose of naltrexone used in these studies (0.25 mg/kg) was a pharmacological stressor and facilitates relapse to alcohol previously shown to be marginally effective in reducing etha seeking (Le et al. 2005). nol intake in msPrats under the same experimental conditions Analysis of variance (ANOVA) of data was used to evalu (Ciccocioppo et al. 2007). ate the results. When appropriate, ANOVA was followed by The msP rats (n=8) were prepared for the study as post-hoc tests. In particular, the effect of acute administration described in Example 1. After acquisition of a stable baseline of pioglitaZone, naltrexone or their combination on alcohol of ethanol intake, alcohol access was restricted to 2 hours a intake (Examples 1 and 2) was evaluated by mean of a two day at the beginning of the dark phase. Water and food were way ANOVA with two within factors (time and treatment). 10 freely available. Animals were tested for the effect of the The effect of chronic administration of pioglitaZone, naltrex combination between pioglitazone (0.0, 10.0, 30.0 mg/kg) one or their combination on alcohol intake (Examples 3 and given at 12 hours and at 1 hour before access to ethanol and 4) was evaluated by mean of a three-way ANOVA with one maltrexone (0.0 and 0.25 mg/kg) injected 2 minutes after the between factor (treatment) and two between factors (days and second pioglitaZone administration. The experiment was con hours). The effect of pioglitazone on reinstatement of alcohol 15 ducted using a within Subject counterbalanced Latine square seeking (Examples 5 and 6) was evaluated by mean of a design where each animal received all drug doses. one-way ANOVA with repeated measures using drug dose as These experiments were conducted at the beginning of the a within subject factor. Alcohol self-administration (Example dark cycle and alcohol, and water and food intakes were 7) in Wistar rats was studied by one-way ANOVA with one monitored at 30, 60, 90 and 120 minutes after ethanol was within factor (dose). Post hoc analysis was carried out using made available. Water and food intakes were not significantly the Newman-Keuls test. modified by the various treatments. Analysis of variance revealed a significant overall effect of Example 1 treatment F(3.7)=5.95 p-0.01 on alcohol intake. As shown in FIG. 2, post-hoc tests demonstrated that both naltrexone Effect of Acute Pioglitazone Administration on 25 alone and naltrexone-piolgitaZone significantly reduced Voluntary Ethanol Intake ethanol intake at 30, 60, and 90 minutes. At 120 minutes, the treatments with naltrexone alone and naltrexone-pioglita The effect of acute pioglitaZone administration on Volun Zone (10 mg/kg) did not show significant effects. In contrast, tary ethanol intake was demonstrated by first training rats to compared to controls, the co-administration of naltrexone-- drink 10% (w/v) alcohol for 24 hours a day (free choice 30 pioglitaZone (30 mg/kg) showed a significant effect also at between water and ethanol). After acquisition of a stable 120 minutes (p<0.05). This data suggests that co-administra baseline of ethanol intake (6-8g/kg bw; daily), alcohol access tion of the two drugs results in an enhancement of their was restricted to 2 hours a day at the beginning of the dark effects, or could result in an increased duration of naltrexone phase. Water and food were freely available. effect. Once stable ethanol drinking baseline was reached (also 35 under limited access conditions), rats (n=7) were tested for Example 3 the effect of pioglitazone (0.0, 10.0, 30.0 mg/kg) using a within Subject counterbalanced Latine Square design where Effect of Subchronic Pioglitazone Administration on each animal received all drug doses. Before starting the treat Voluntary Ethanol Intake ment, rats were trained to gavage administration procedures 40 for three days, during which they received vehicle (distilled The effect of subchronic pioglitazone administration was water). demonstrated using rats trained to drink 10% (v/v) alcohol for Treatments were carried out at intervals of at least three 24 hours a day (free choice between water and ethanol) until days. Before each ethanol drinking experiment, msP rats a stable baseline of ethanol intake was reached. At this point, received two doses of pioglitazone or vehicle at 12 hours and 45 msP rats (N=9/group) were tested for the effect of pioglita at 1 hour before access to ethanol. Drinking experiments were Zone (0.0, 10.0, or 30.0 mg/kg) on ethanol intake using a conducted right at the beginning of the dark cycle. Alcohol, between Subject design, in which each group of animals water and food intakes were monitored at 30, 60, 90 and 120 received a different dose of drug. Before starting the treat minutes after ethanol was made available. ment, rats were trained to gavage administration procedures Analysis of variance revealed the absence of a significant 50 for three days, during which they received vehicle (distilled treatment effect on ethanol intake F(2,6)=1.22 NS. However, water). a significant treatment time interaction was detected F(6,18) PioglitaZone treatment was continued for seven consecu =6.87 p-0.01. As shown in FIG. 1, post-hoc tests revealed tive days, and drug (or vehicle) was administered twice a day that acute treatment with 30 mg/kg of pioglitaZone signifi at 12 hour and at 1 hour before the beginning of dark period of cantly reduced ethanol consumption at 2 hours but not at 30, 55 the light/dark cycle. Alcohol, water and food intakes were 60, or 90 minutes. The selectivity effect was demonstrated by monitored at 2, 8 and 24 hours. Fluids and food intakes were the lack of significant effects on water and food consumption monitored for three additional days after the end of the drug (data not shown). treatment period. Sub-chronic (7 days) pioglitaZone administration signifi Example 2 60 cantly reduced Voluntary ethanol intake in msPrats. Analysis of variance revealed a significant overall effect of treatment F Effect of Acute Pioglitazone Plus Naltrexone (2.33)=9.51; p<0.01. As shown by post-hoc tests, the effect Administration on Voluntary Ethanol Intake appeared from the first day of treatment at the highest drug dose (FIGS. 3A, 3B and 3C). The effect progressively In this experiment, the effect of the co-administration of 65 increased during treatment, and starting from the 4" day of pioglitaZone and naltrexone on alcohol consumption was treatment, both drug doses (10 and 30 mg/kg) significantly examined to demonstrate that PPARYagonists could enhance reduced ethanol intake. US 8,426,439 B2 39 40 During treatment, water consumption was rather low and ethanol responding progressively decreased. The day after was not significantly affected by drug treatment. Conversely, the last extinction session, rats were Subjected to the reinstate food intake (FIG. 3D) was significantly increased by piogli ment test. The animals were treated OS with pioglitazone tazone F (2.33)=7.34 p<0.01). The effect was higher after (0.0, 10.0, or 30.0 mg/kg) at 12 hours and 1 hour before the administration of the lowest dose (10 mg/kg) of drug. At the reinstatement test. Yohimbine (1.25 mg/kg, IP) was given 30 end of the treatment, rats gradually recovered from the effect min after the last pioglitaZone administration. of the drug and ethanol intake and progressively returned at Animals received all drug treatments according to a coun pre-treatment levels (data not shown). terbalance Latin square design. A 3-day interval, during which animals were Subjected to extinction sessions, was Example 4 10 allowed between drug tests. In the reinstatement test, active and inactive lever responses were recorded. Effect of Subchronic Pioglitazone Plus Naltrexone A stable baseline of responding for 10% (v/v) alcohol was Administration on Voluntary Ethanol Intake established in 15 days. Following this alcohol self-adminis tration phase, extinction training began. During the extinction The effect of chronic co-administration of pioglitaZone and 15 phase, responding progressively decreased, and the last maltrexone on alcohol consumption was studied to evaluate if extinction day values were 16.1+3.9. The intraperitoneal PPARY agonists could also enhance the inhibitory action of administration of the alpha-2 adrenoceptorantagonistyohim opioid antagonists on ethanol intake after repeated treat bine at the dose of 1.25 mg/kg significantly reinstated the ments. As in the studies described in Example 2, a naltrexone operant response for alcohol F(1,18)=22.78 p-0.01. As dose (0.25 mg/kg) previously shown to be marginally effec shown by the analysis of variance, pre-treatment with piogli tive in reducing ethanol intake in msP rats was used (Cicco taZone significantly reduced the effect of yohimbine cioppo et al. 2007). According to a between-subject design, F(2.9)=12.21, p<0.01 (FIG. 5). Post-hoc analysis demon four groups of msP rats (N=9/group) were prepared as strated a significant inhibition of reinstatement following described in Example 3. Specifically, once a stable baseline of administration of 30 mg/kg of pioglitazone (p<0.01). daily ethanol consumption was reached, different groups of 25 At the lowest dose (10 mg/kg), pioglitaZone showed a clear msP rats were tested for the effect of pioglitazone in combi trend (p=0.07) to an inhibition of yohimbine effect. Analysis nation with naltrexone. For seven consecutive days, msPrats of inactive lever responding revealed absence of treatment received pioglitazone treatments (0.0, 10.0, or 30.0 mg/kg) at effects at this lever. This indicated the selectivity of the effect 12 hour and at 1 hour before the beginning of the dark of the of yohimbine in eliciting reinstatement of alcohol seeking. light/dark cycle, while naltrexone (0.0 and 0.25 mg/kg) was 30 injected 2 minutes after the second pioglitaZone administra Example 6 tion. Alcohol, water and food intakes were monitored at 2, 8 and 24 hours. Fluids and food intakes were monitored for Effect of Acute Pioglitazone Administration on three additional days after the end of the drug treatment Cue-Induced Reinstatement of Alcohol Seeking period. 35 Sub-chronic (7 days) administration of naltrexone or nal In this experiment to demonstrate the effect of TZDs on trexone-pioglitaZone significantly reduced Voluntary ethanol cue-induced relapse to alcohol use, msP rats (n=14) were intake in msPrats. Analysis of variance revealed a significant trained to operantly self-administer 10% ethanol or water in overall effect of treatment F(3.32)=9.59 p<0.01). As shown 30 min daily session on an FR-1 schedule of reinforcement, by post-hoc tests (FIGS. 4A, 4B and 4C), naltrexone signifi 40 where each response resulted in delivery of 0.1 ml of fluid. cantly reduced ethanol intake at 2 hours (p<0.05) but not at 8 Ethanol availability was signalled by the odor of an orange and 24 hours. In addition, the effect progressively decayed extract, which served as a discriminative stimulus. In addi during treatment days. Animals treated with pioglitaZone plus tion, each lever press resulting in delivery of ethanol was maltrexone, instead, significantly reduced their drinking at all paired with illumination of the house light for 5s (S/CS). time points tested (2, 8 and 24 hours). This effect remained 45 For water, anise odor and a 5 sec white noise were employed significant for the entire period of treatment. These results as discriminative and contiguous cues (S/CS), respectively. indicate that pioglidaZone and naltrexone co-administration Rats were than Subjected to daily extinction sessions, during may result in additive or synergistic effects. which lever presses progressively decreased. During treatment, water consumption was rather low and The reinstatement test was conducted by re-exposing them was not significantly affected by drug treatment. Conversely, 50 to the conditioned stimuli predictive of ethanol or water avail food intake was significantly increased by pioglitaZone F(3. ability but in the absence of the fluids. Pioglitazone (0.0, 10.0, 32)=5.34 p<0.05 (FIG. 4D). The effect was higher after 30.0 mg/kg) was given 12 hours and 1 hour before the rein administration of the lowest dose (10 mg/kg) of drug. At the statement test. Experiments were conducted at the beginning end of the treatment, rats gradually recovered from the effect of the dark phase of the light/dark cycle. Animals received all of the drug and ethanol intake progressively returned at pre 55 drug treatments according to a counterbalance Latin square treatment levels. design, and a 3-day interval was allowed between reinstate ment sessions. In the reinstatement test, active and inactive Example 5 lever responses were recorded. Throughout the conditioning phase, in which animals dis Effect of Acute Pioglitazone Administration on 60 criminated between alcohol or water availability, rats Yohimbine-Induced Reinstatement of Alcohol responded at a higher level for alcohol. ANOVA showed a Seeking significant overall effect of conditioning F(1.28)=41.89, p-0.01. On the last day of the discrimination period, animals To demonstrate the effect of TZDs on stress-induced reached a lever pressing response of about 120 in 30 min. relapse to alcohol seeking, following acquisition of a stable 65 while the response for water was 20. During extinction, lever baseline of 10% ethanol, responding msP rats (n=10) were pressing progressively decreased to 5.87+1.07 of the last Subjected to an extinction period (14 days) during which extinction day. In the reinstatement test, the ANOVA showed US 8,426,439 B2 41 42 that cues had a significant overall effect on alcohol-seeking ing was highly significant at 24 hours (p<0.01). The selectiv F(1.28)=30.4, p<0.01. A more detailed analysis showed a ity effect was demonstrated by the lack of significant effects robust reinstatement of responding under the S"/CS" on water and food consumption (data not shown). (p<0.01) but not under the S/CS compared with the last day of extinction. As shown in FIG. 6, conditioned reinstatement Example 9 of alcohol-seeking was not significantly modified by pre treatment with pioglitaZone. Responses at the inactive lever Effect of IP Administration of the PPARY Antagonist were not influenced by the treatment (data not shown). GW9662 on Pioglitazone-Induced Reduction of Ethanol Intake Example 7 10 This experiment demonstrated that the effect of pioglita Effect of Ciglitazone Administration on Ethanol Zone on ethanol intake was mediated by activation of PPARY Self-Administration in Wistra Rats receptors. After acquisition of a stable baseline of ethanol intake, msPrats (n=22) were tested for the effect of GW9662 This study was performed to demonstrate the effect of 15 on pioglitaZone-induced reduction of ethanol intake. Rats pioglitazone on ethanol intake extends also to other PPARY were treated with 30 mg/kg of pioglitazone given OS 1 hour agonists. The effect of ciglitaZone, a structurally different before access to ethanol. GW9662 was administered IP 30 TDZ, on ethanol-self-administration was determined. In min after pioglitaZone administration, and additional 30 min addition, to verify that the effect observed with pioglitazone were awaited before giving ethanol access to rats. Before extends to other experimental alcohol intake models, these starting the treatment, rats were trained to gavage and IP studies were performed in heterogeneous Wistar rats under administration procedures for three days. Experiment was operant self-administration conditions. conducted in a between Subject design (n=22). Another group Wistra rats (n=7) were trained to self-administer ethanol 30 of msP rats (n=22) received GW9662 alone to demonstrate min/day under FR1 schedule of reinforcement. Once a stable the effect of PPARY blockade on ethanol consumption. Drink level of responding was reached, in a within Subject counter 25 ing experiments started at the beginning of the dark cycle. balance order (Latin square design), rats were treated with Alcohol, water and food intakes were monitored at 2, 8 and 24 ciglitazone (0.0, 5.0 or 20.0 mg/kg) given IP 30 minutes hours after ethanol was made available. before the beginning of the self-administration session. The As shown in FIG. 9A, analysis of variance revealed that number of responses to the active and inactive levers were blockade of PPARY receptors by GW9662 did not modify recorded. A 3-day interval was allowed between self-admin 30 ethanol drinking in msP rats F(2.18)=0.40 NS. However, istration sessions. analysis of variance revealed a significant treatment effect on During ethanol self-administration, Wistar rats acquired ethanol intake F(3,24)=18.64 p <0.01 following administra robust operant alcohol responding. At the end of this phase, tion of pioglitazone (FIG.9B). Newman-Keuls tests revealed rats pressed the alcohol lever an average of 30-35 times in that treatment with 30 mg/kg of pioglitaZone significantly 30-min. At this point, animals were treated with ciglitazone 35 reduced ethanol consumption at 8 and 24 hours (p<0.01). IP. Results showed that ciclitazone treatment significantly Pretreatment with GW9662 blocked the effect of pioglita reduced ethanol self-administration F(2,6)=5.87 p-0.05. Zone in a dose related manner. Water and food consumption Responding at the inactive lever was very low and was not were not affected by drug treatments (data not shown). affected by drug treatment F(2,6)=1.52 N.S. Post hoc tests showed that ethanol self-administration was significantly 40 Example 10 reduced following administration of the highest dose of drug (FIG. 7). Effect of ICV Administration of the PPARY Antagonist GW9662 on Pioglitazone-Induced Example 8 Reduction of Ethanol Intake 45 Effect of Acute Rosiglitazone Administration on This experiment demonstrated that the effect of pioglita Voluntary Ethanol Intake Zone on ethanol intake is mediated by activation of brain PPARY receptors. For this purpose, msP rats (n=6) were The ability of another TZD, rosiglitazone, to reduce etha treated with GW9662 (5 g/rat) ICV to selectively block nol intake was demonstrated. MsP rats were first trained to 50 brain PPARY receptors, while pioglitazone (30 mg/kg) was drink 10% (w/v) alcohol for 24 hours a day (free choice given OS. The experiment was conduced using a within Sub between water and ethanol). Once stable ethanol drinking ject counterbalanced Latine square design, where each ani baseline was reached (6-8 g/kg/day), rats (n=28) were tested mal received all drug doses. for the effect of rosiglitazone (0.0. 7.5 and 15 mg/kg) using a The drinking experiments were conducted at the beginning between Subject design. Before starting the treatment, rats 55 of the dark cycle, and alcohol, water and food intakes were were trained to gavage administration procedures for three monitored at 2, 8 and 24 hours after ethanol was made avail days, during which they received vehicle (distilled water). able. RosiglitaZone was given twice, at 12 hours and 1 hour before Analysis of variance revealed a significant treatment effect access to ethanol. Drinking experiments started at the begin on ethanol intake F(3,5)=12.93 p-0.001). As shown in FIG. ning of the dark cycle. Alcohol, water and food intakes were 60 10, post-hoc Newman-Keuls tests revealed that treatment monitored at 2, 8 and 24 hours after ethanol was made avail with 30 mg/kg of pioglitaZone significantly reduced ethanol able. consumption at 2 hours (p<0.05) 8 hours (p<0.05) and at 24 Analysis of variance revealed a significant treatment effect hours (p<0.01). ICV administration of GW9662 did not sig on ethanol intake F(2.18)=0.4 p<0.05. As shown in FIG. 8, nificantly affect ethanol intake perse. However it completely post-hoc Newman-Keuls tests revealed that acute treatment 65 prevented the effect of pioglitazone. Water and food con with 15 mg/kg of rosiglitaZone significantly reduced ethanol Sumption were not affected by drug treatments (data not consumption at 2 hours (p<0.05). Inhibition of ethanol drink shown). US 8,426,439 B2 43 44 Example 11 Throughout the conditioning phase, in which animals dis criminated between alcohol or water availability, rats Effect of Acute Naltrexone Administration on responded at a higher level for alcohol. During extinction, Yohimbine-Induced Reinstatement of Alcohol lever pressing progressively decreased. In the reinstatement Seeking test, the ANOVA showed that cues had a significant overall effect on alcohol-seeking F(1.8)–36.31, p<0.01. A more The inability of naltrexone to reduce yohimbine-induced detailed analysis showed a robust reinstatement of respond reinstatement of alcohol use was demonstrated. Following ing under the S"/CS" (p<0.01) but not under the S/CS acquisition of a stable baseline of 10% ethanol, responding compared with the last day of extinction. As shown in FIG. msP rats (n=10) were subjected to an extinction period (14 10 12, conditioned reinstatement of alcohol-seeking was signifi days) during which ethanol responding progressively cantly reduced by naltrexone F(2,8)=15.90; p<0.01). Post hoc analysis revealed that both doses (0.25 and 1.0 mg/kg) of decreased. The day after the last extinction session, rats were the opioid antagonist tested significantly reduced reinstate subjected to the reinstatement test. ment of ethanol seeking (p<0.01). Responses at the inactive To determine whether naltrexone was able to prevent the effect of the pharmacological stressor yohimbine, animals 15 lever were not influenced by the treatment (data not shown). (n=7) were treated IP with the opioidantagonist (0.0, 0.25 and Example 13 1.0 mg/kg) 1 hour before the reinstatement test. Yohimbine (1.25 mg/kg, IP) was given 30 min after naltrexone adminis Effect of Co-Administration of Pioglitazone and tration. Animals received all drug treatments according to a Naltrexone on Yohimbine- and Cue-Induced counterbalance Latin square design. A 3-day interval, during Reinstatement of Alcohol Seeking which animals were subjected to extinction sessions, was allowed between drug tests. In the reinstatement test, active The combined effect of a PPARYagonist, pioglitazone, and and inactive lever responses were recorded. an opioid antagonist, naltrexone, on various inducers of rein A stable baseline of responding for 10% (v/v) alcohol was 25 stated alcohol seeking was determined. established in 15 days. Following this alcohol self-adminis For yohimbine-induced reinstatement of ethanol seeking, tration phase, extinction training began. During the extinction after acquisition of a stable baseline of 10% ethanol respond phase, responding progressively decreased. The intraperito ing, msPrats (n=9) were subjected to an extinction period (14 neal administration of the alpha-2 adrenoceptor antagonist days) during which ethanol responding progressively yohimbine at the dose of 1.25 mg/kg significantly reinstated 30 decreased. The day after the last extinction session, rats were the operant response for alcohol F(18)=19.99 p-0.01. As subjected to the reinstatement test. shown by the analysis of variance, pre-treatment with naltr To evaluate whether combination of naltrexone plus piogli exone did not significantly reduce the effect of yohimbine taZone was able to prevent the effect of the pharmacological F(2,8)=0.46, NS (FIG. 11). Analysis of inactive lever stressor yohimbine, animals were treated IP with the opioid responding revealed absence of treatment effects at this lever 35 antagonist (1.0 mg/kg) and OS with the TDZ (30 mg/kg) 1 (data not shown). This indicates the selectivity of the effect of hour before the reinstatement test. Yohimbine (1.25 mg/kg, yohimbine in eliciting reinstatement of alcohol seeking. IP) was given 30 min after naltrexone/pioglitaZone adminis tration. Animals received all drug treatments according to a Example 12 counterbalance Latin square design. A 3-day interval, during 40 which animals were Subjected to extinction sessions, was Effect of Acute Naltrexone Administration on allowed between drug tests. In the reinstatement test, active Cue-Induced Reinstatement of Alcohol Seeking and inactive lever responses were recorded. For cue-induced reinstatement of alcohol seeking, another The ability of naltrexone to reduce cue-induced reinstate group of msP rats (n=10) were trained to operantly self ment of alcohol seeking was demonstrated. In this experi 45 administer 10% ethanol or water in 30 min daily session on an ment, msP rats (n=9) were trained to operantly self-adminis FR-1 schedule of reinforcement, where each response ter 10% ethanol or water in 30 min daily session on an FR-1 resulted in delivery of 0.1 ml of fluid. Ethanol availability was schedule of reinforcement, where each response resulted in signalled by the odor of an orange extract, which served as a delivery of 0.1 ml of fluid. Ethanol availability was signalled discriminative stimulus. In addition, each lever press result by the odor of an orange extract, which served as a discrimi 50 ing in delivery of ethanol was paired with illumination of the native stimulus. In addition, each lever press resulting in house light for 5s (S/CS). For water, anise odor and a 5 sec delivery of ethanol was paired with illumination of the house white noise were employed as discriminative and contiguous light for 5s (S/CS). For water, anise odor and a 5 sec white cues (S/CS), respectively. Rats were then subjected to a noise were employed as discriminative and contiguous cues daily extinction sessions, during which lever presses progres (S/CS), respectively. Rats were than subjected to a daily 55 sively decreased. extinction sessions during which lever presses progressively A reinstatement test was conducted by re-exposing them to decreased. the conditioned stimuli predictive of ethanol or water avail Reinstatement tests were conducted by re-exposing them ability, but in the absence of the fluids. Naltrexone (1.0 to the conditioned stimuli predictive of ethanol or water avail mg/kg) and pioglitaZone were co-administered 1 hour before ability, but in the absence of the fluids. Naltrexone (0.0, 0.25 60 the reinstatement test. Experiments were conducted at the and 1.0 mg/kg) was given one hour before the reinstatement beginning of the dark phase of the light/dark cycle. Animals test. Experiments were conducted at the beginning of the dark received all drug treatments according to a counterbalance phase of the light/dark cycle. Animals received all drug treat Latin square design and a 3-day interval was allowed between ments according to a counterbalance Latin Square design, and reinstatement sessions. In the reinstatement test, active and a 3-day interval was allowed between reinstatement sessions. 65 inactive lever responses were recorded. In the reinstatement test, active and inactive lever responses For yohimbine-induced reinstatement of alcohol seeking, were recorded. rats reached a stable baseline of responding for 10% (v/v) US 8,426,439 B2 45 46 alcohol in 15 days. Following this time period, alcohol self shown). Water consumption was very low and was not modi administration phase extinction training began. During the fied by drug administration (data not shown). extinction phase, responding progressively decreased. The intraperitoneal administration of the alpha-2 adrenoceptor Example 15 antagonist yohimbine at the dose of 1.25 mg/kg significantly 5 reinstated the operant response for alcohol F(18)=12.86 Effect of Acute Pioglitazone Plus Mirtazapine p-0.01. As shown by the analysis of variance, pre-treatment Administration on Voluntary Ethanol Intake with naltrexone plus pioglitaZone significantly reduced the effect of yohimbine F(2,8)=5.71, p<0.01 (FIG. 13A). The effect of the co-administration of pioglitazone and Analysis of inactive lever responding revealed absence of 10 mirtazapine on alcohol consumption was studied to demon treatment effects at this lever. strate that co-treatment with PPARYagonists and this antide pressant had synergistic effects on ethanol intake inhibition. For cue-induced reinstatementofalcohol seeking, msPrats For this purpose, a low dose of mirtazapine (5.0 mg/kg. OS) rapidly learned to discriminate between alcohol or water that did not reduce ethanol intake in msP rats in a pilot study availability; rats responded at a higher level for alcohol. Dur 15 was used. Also, a pioglitaZone dose (10 mg/kg, OS) was ing extinction, lever pressing progressively decreased. In the chosen Such that it did not significantly affect alcohol intake reinstatement test, the ANOVA showed that cues had a sig perse. nificant overall effect on alcohol-seeking F(1.9)=31.83, MsP rats were first trained to drink 10% (w/v) alcohol for p-0.01. A more detailed analysis showed a robust reinstate 24 hours a day (free choice between water and ethanol). Once ment of responding under the S/CS" (p<0.01) but not under stable ethanol drinking baseline was reached (6-8 g/kg/day), the S/CS compared with the last day of extinction. As in a between subject design, msP rats (n=34) were tested for shown in FIG. 13B, conditioned reinstatement of alcohol the effect of pioglitaZone, mirtazapine or their combination. seeking was significantly reduced by co-administration of Rats treated with drug vehicles served as a control. Before maltrexone and pioglitazone F(2.9)=16.58; p <0.01. starting the treatment, rats were trained to gavage administra Responses at the inactive lever were not influenced by the 25 tion for three days, during which they received drugs vehicle treatment (data not shown). (distilled water). PioglitaZone and mirtazapine were given twice, at 12 hours and 1 hour before access to ethanol. Drink Example 14 ing experiments started at the beginning of the dark cycle. Alcohol, water and food intakes were monitored at 2, 8 and 24 Effect of Acute Pioglitazone Plus Fluoxetine 30 hours after ethanol was made available. Administration on Voluntary Ethanol Intake Analysis of variance revealed a significant overall effect of treatment F(3,30)=12.50 p<0.01 on alcohol intake. As In this experiment, the effect of the co-administration of shown in FIG. 15, post-hoc tests demonstrated that a low dose pioglitaZone and fluoxetine on alcohol consumption was of pioglitaZone alone or mirtazapine alone did not signifi studied to demonstrate that co-treatment with PPARY ago 35 cantly modify ethanol intake in msP rats. However, co-ad nists, e.g., TZDS, and antidepressants, e.g., selective seroto ministration of the two agents resulted in a marked inhibition nin uptake inhibitors, has synergistic effects on ethanol intake of ethanol consumption at 2 and 8 hours (p<0.05); a signifi inhibition. For this purpose, a low dose of fluoxetine (3.0 cant reduction of ethanol intake at 2 hours was also reported mg/kg. OS) that did not reduce ethanol intake in msPrats in a for pioglitaZone alone (p<0.05). These data Suggest that co pilot study was used. Also, a pioglitaZone dose (10 mg/kg, 40 administration of the two drugs exert Synergistic inhibitory OS) was chosen that does not significantly affect alcohol actions on ethanol drinking. intake perse. A nonsignificant trend to an increase of food intake was MsP rats were first trained to drink 10% (w/v) alcohol for observed following drug treatments (data not shown). Water 24 hours a day (free choice between water and ethanol). Once consumption was very low and was not modified by drug a stable ethanol drinking baseline was reached (6-8 g/kg/day), 45 administration (data not shown) in a between subject design, msP rats (n=34) were tested for the effect of pioglitazone, fluoxetine or their combination. Example 16 Rats treated with drug vehicles served as a control. Before starting the treatment, rats were trained to gavage administra Effect of Acute Pioglitazone Plus Topiramate tion for three days, during which they received drugs vehicle 50 Administration on Voluntary Ethanol Intake (distilled water). Pioglitazone and fluoxetine were given twice, at 12 hours and 1 hour before access to ethanol. Drink In this experiment, the effect of the co-administration of ing experiments started at the beginning of the dark cycle. pioglitaZone and topiramate on alcohol consumption was Alcohol, water, and food intakes were monitored at 2, 8 and studied to demonstrate that co-treatment with PPARY ago 24 hours after ethanol was made available. 55 nists and this antiepileptic has synergistic effects on ethanol Analysis of variance revealed a significant overall effect of intake inhibition. For this purpose, a low dose of topiramate treatment F(3,30)=5.37 p-0.01 on alcohol intake. As shown (30.0 mg/kg, OS) that did not reduce ethanol intake in msP in FIG. 14, post-hoc tests demonstrated that a low dose of rats in a pilot study was used. Also, a pioglitaZone dose (10 pioglitaZone alone or fluoxetine alone did not significantly mg/kg. OS) was chosen such that it did not significantly affect modify ethanol intake in msP rats. However, co-administra 60 alcohol intake perse. tion of the two agents resulted in a marked inhibition of MsP rats were first trained to drink 10% (w/v) alcohol for ethanol consumption at 2 and 8 hours (p<0.01), as well as at 24 hours a day (free choice between water and ethanol). Once 24 hours (p<0.05). These data Suggest that co-administration stable ethanol drinking baseline was reached (6-8 g/kg/day), of the two drugs exert Synergistic inhibitory actions on etha in a between subject design, msP rats (n=34) were tested for nol drinking. 65 the effect of pioglitaZone, topiramate or their combination. A modest, nonsignificant trend to an increase of food Rats treated with drug vehicles served as a control. Before intake was observed following drug treatment (data not starting the treatment, rats were trained to gavage administra US 8,426,439 B2 47 48 tion for three days, during which they received drugs vehicle strate that co-treatment with PPARYagonists and this antiepi (distilled water). PioglitaZone and topiramate were given leptic has synergistic effects on ethanol intake inhibition. For twice, at 12 hours and 1 hour before access to ethanol. Drink this purpose, a low dose of gabapentin (60.0 mg/kg, OS) that ing experiments started at the beginning of the dark cycle. did not reduce ethanol intake in msPrats in a pilot study was Alcohol, water and food intakes were monitored at 2, 8 and 24 used. Also a pioglitaZone dose (10 mg/kg, OS) was chosen, hours after ethanol was made available. Analysis of variance revealed a significant overall effect of Such that it did not significantly affect alcohol intake perse. treatment F(3,30)=4.35 p-0.01 on alcohol intake. As shown MsP rats were first trained to drink 10% (w/v) alcohol for in FIG. 16, post-hoc tests demonstrated that a low dose of 24 hours a day (free choice between water and ethanol). Once pioglitaZone alone or topiramate alone did not significantly stable ethanol drinking baseline was reached (6-8 g/kg/day), modify ethanol intake in msP rats. However, co-administra 10 in a between subject design, msP rats (n=36) were tested for tion of the two agents resulted in a marked inhibition of the effect of pioglitaZone, gabapentin or their combination. ethanol consumption at 2, 8 and 24 hours (p<0.05); a signifi Rats treated with drug vehicles served as a control. Before cant reduction of ethanol intake at 2 hours was also reported starting the treatment, rats were trained to gavage administra for topiramate alone (p<0.05). These data Suggest that co tion for three days, during which they received drugs vehicle administration of the two drugs exert Synergistic inhibitory 15 (distilled water). PioglitaZone and topiraate were given twice, actions on ethanol drinking. at 12 hours and 1 hour before access to ethanol. Drinking A nonsignificant trend to an increase of food intake was experiments started at the beginning of the dark cycle. Alco observed following drug treatments (data not shown). Water hol, water and food intakes were monitored at 2, 8 and 24 consumption was very low and was not modified by drug hours after ethanol was made available. administration (data not shown). Analysis of variance revealed a significant overall effect of treatment F(3.7)=3.31 p-0.05 on alcohol intake. As shown Example 17 in FIG. 18, post-hoc tests demonstrated that a low dose of pioglitaZone alone or gabapentin alone did not significantly Effect of Acute Pioglitazone Plus Levetiracetam modify ethanol intake in msP rats. Conversely, co-adminis Administration on Voluntary Ethanol Intake 25 tration of the two agents resulted in a marked inhibition of The effect of the co-administration of pioglitazone and ethanol consumption at 2 and 8 hours (p<0.05). These data levetiracetam on alcohol consumption was studied to demon Suggest that co-administration of the two drugs exerts Syner strate that co-treatment with PPARYagonists and this antiepi gistic inhibitory actions on ethanol drinking. leptic has synergistic effects on ethanol intake inhibition. For A nonsignificant trend to an increase of food intake was this purpose, a low dose of levetiracetam (100.0 mg/kg, OS) observed following drug treatments (data not shown). Water that did not reduce ethanol intake in msP rats in a pilot study consumption was very low and was not modified by drug was used. Also, a pioglitaZone dose (10 mg/kg, OS) was administration (data not shown). chosen, such that it did not significantly affect alcohol intake perse. Example 19 MsP rats were first trained to drink 10% (w/v) alcohol for 35 24 hours a day (free choice between water and ethanol). Once Effect of Acute Pioglitazone Plus Ondansetron stable ethanol drinking baseline was reached (6-8 g/kg/day), Administration on Voluntary Ethanol Intake in a between subject design, msP rats (n=33) were tested for the effect of pioglitazone, levetiracetam or their combination. The effect of the co-administration of pioglitazone and Rats treated with drug vehicles served as a control. Before 40 ondansetron on alcohol consumption was studied to demon starting the treatment, rats were trained to gavage administra strate that co-treatment with PPARYagonists and this seroto tion for three days, during which they received drugs vehicle nin-3 (5-HT3) receptor selective antagonist have synergistic (distilled water). Pioglitazone and levetiracetam were given effects on ethanol intake inhibition. For this purpose, a low twice, at 12 hours and 1 hour before access to ethanol. Drink dose of ondansetron (1.0 mg/kg, IP) that did not reduce etha ing experiments started at the beginning of the dark cycle. 45 nol intake in msP rats in a pilot study was used. Also, a Alcohol, water and food intakes were monitored at 2, 8 and 24 pioglitaZone dose (10 mg/kg, OS) was chosen, such that it did hours after ethanol was made available. not significantly affect alcohol intake perse. Analysis of variance revealed a significant overall effect of MsP rats were first trained to drink 10% (w/v) alcohol for treatment F(3.29)=3.76 p-0.05 on alcohol intake. As shown 24 hours a day (free choice between water and ethanol). Once in FIG. 17, post-hoc tests demonstrated that a low dose of 50 stable ethanol drinking baseline was reached (6-8 g/kg/day), pioglitaZone alone or levetiracetamalone did not significantly in a between subject design, msP rats (n=36) were tested for modify ethanol intake in msP rats. Conversely, co-adminis the effect of pioglitaZone, ondansetron, or their combination. tration of the two agents resulted in a marked inhibition of Rats treated with drug vehicles served as a control. Before ethanol consumption at 2 hours (p<0.01), as well as at 8 and starting the treatment, rats were trained to gavage administra 24 hours (p<0.05). These data Suggest that co-administration 55 tion for three days, during which they received drugs vehicle of the two drugs exerts synergistic inhibitory actions on etha (distilled water). PioglitaZone and ondansetron were given nol drinking. twice, at 12 hours and 1 hour before access to ethanol. Drink Food and water consumption was not modified by drug ing experiments started at the beginning of the dark cycle. administration (data not shown). Alcohol, water and food intakes were monitored at 2, 8 and 24 60 hours after ethanol was made available. Example 18 Analysis of variance revealed a nonsignificant overall effect of treatment F(3.32)=2.73 p <0.05, but a significant Effect of Acute Pioglitazone Plus Gabapentin treatment time interaction on alcohol intake was observed Administration on Voluntary Ethanol Intake F(6,64)=2.29 p<0.0.5). As shown in FIG. 19, post-hoc tests 65 demonstrated that a low dose of pioglitaZone alone or The effect of the co-administration of pioglitazone and ondansetron alone did not significantly modify ethanol intake gabapentin on alcohol consumption was studied to demon in msP rats. However, co-administration of the two agents US 8,426,439 B2 49 50 resulted in a marked inhibition of ethanol consumption at 24 (1) presence of the ventromedial distal flexion response; (2) hours (p<0.05). Water and food consumption was very low tail stiffness/rigidity; and (3) tremors (Schulteis et al. 1995). and was not modified by drug administration (data not Each sign was rated during a 3-5 min observation period on a shown). These data Suggest that co-administration of the two scale of 0-2 (Macey et al., 1996: Schulteis, et al., 1995). All drugs exerts synergistic inhibitory actions on ethanol drink 5 signs were cumulated to yield an overall withdrawal severity 1ng. SCO. Twelve hours after the last ethanol administration, animals Example 20 treated with pioglitazone vehicle showed marked withdrawal symptoms. The analysis of variance showed an overall effect Effect of Acute Pioglitazone Plus Antalarmin 10 of pioglitaZone treatment that reduced tail rigidity Administration on Voluntary Ethanol Intake F(4.25)=11.98 p-0.001 (FIG. 21). Post hoc tests revealed The effect of the co-administration of pioglitazone and that alcohol withdrawal signs were significantly reduced after antalarmin on alcohol consumption was studied to demon administration of both 10 mg/kg and 30 mg/kg of pioglita strate that co-treatment with PPARY agonists and this corti 15 Zone, with a highly significant effect of tail rigidity (p<0.01), cotrophin releasing factor CRF1 receptor selective antagonist tremors (p<0.01), and ventromedial limb retraction (p<0.01). has synergistic effects on ethanol intake inhibition. For this Interestingly, while measuring withdrawal score, two out of purpose, a low dose of antalarmin (15.0 mg/kg, IP) that mod the 7 animals of vehicle treated groups showed convulsion. estly reduced ethanol intake in msP rats in a pilot study was Conversely, none of the 12 rats treated with pioglitazone used. Also, a pioglitaZone dose (10 mg/kg, OS) was chosen, showed seizures. These data Suggest that pioglitaZone not Such that it did not significantly affect alcohol intake perse. only helps to reduce ethanol drinking (see previous experi MsP rats were first trained to drink 10% (w/v) alcohol for ments), but it also possesses the ability to reduce or control 24 hours a day (free choice between water and ethanol). Once alcohol withdrawal syndrome and related symptoms, includ stable ethanol drinking baseline was reached (6-8 g/kg/day), ing seizures. in a between subject design, msP rats (n=32) were tested for 25 the effect of pioglitaZone, antalarmin or their combination. Example 22 Rats treated with drug vehicles served as a control. Before starting the treatment, rats were trained to gavage administra Effect of Pioglitazone on Alcohol Abuse in Humans tion for three days during which they received drugs vehicle (distilled water). PioglitaZone and antalarmin were given 30 An observational study of human patients using pioaglita twice, at 12 hours and 1 hour before access to ethanol. Drink ing experiments started at the beginning of the dark cycle. Zone (Actos(R) for the treatment of diabetes was performed to Alcohol, water and food intakes were monitored at 2, 8 and 24 demonstrate that PPARY agonists, alone or in combination hours after ethanol was made available. with opioid antagonists, are effective in reducing ethanol abuse. Analysis of variance revealed a significant overall effect of 35 treatment F(3.28)=3.29 p-0.05 on alcohol intake. As shown A total of 12 patients were enrolled in the study. 4 patients in FIG. 20, post-hoc tests demonstrated that a low dose of (2 male and 2 female) received only psychotherapy (Control; pioglitaZone alone or antalarmin alone did not significantly CRT); 4 patients (male) received naltrexone 50 mg/day modify ethanol intake in msP rats. However, co-administra (NTX)+psychotherapy; and 4 patients (3 male and 1 female) tion of the two agents resulted in a marked inhibition of 40 received pioglitazone 30 mg/day (Actos(R); ACT)+psycho ethanol consumption at 8 (p<0.01) and 24 hours (p<0.05); a therapy. The patients ages ranged from 25 to 45 years old. All significant reduction of ethanol intake at 8 hours was also patients had previous unsuccessful experiences of alcohol reported for antalarmin alone (p<0.05). These data Suggest detoxification. No major psychiatric co-morbidity was iden that co-administration of the two drugs exerts Synergistic tified. Patient treated with Actos(R were all diagnosed with inhibitory actions on ethanol drinking. 45 diabetes. Water and food consumption was not modified by drug Patients were scored at Timepoint 0 (immediately before administration (data not shown). beginning the treatment) for various psychological indica tors. Anxiety was determined using the S.T.A.I.Y-1 Ques Example 21 tioner, obsession for alcohol was determined using the 50 Obsessive Compulsive Drinking Scale questioner; and Effect of Pioglitazone Administration on Alcohol depression was determined using the M.A.D.R.S 10 Item Withdrawal questioner. Daily and weekly ethanol consumption was also scored. Patients were also tested one a week for anxiety, The effect of pioglitazone administration on alcohol with depression, and obsession to drink. drawal was determined in rats. Male Wistar rats were sub 55 In addition, patients’ blood samples were taken at Time jected to a six days of intermittent alcohol intoxication. Dur point 0 and after four weeks (T1) and 12 weeks (T2) of ing the dark phase, rats received 4 oral administration of treatment. Hematological parameters measured included: 2.5-3.0 g/kg of 20% ethanol. The first ethanol dose was given mean corpuscular Volume (MCV); gamma-GT, aspartate at the beginning of the dark phase. The other 3 daily doses aminotransferase (AST): alanine aminotransferase (ALT); were administered at intervals of 3 hours. Rats were not 60 and carbohydrate-deficient transferring (CDT). MCV and injected during the light phase of the light/dark cycle. Tar CDT are biomarkers for ethanol consumption, and GGT, ALT geted blood alcohol levels were 250-300 mg/dl. After 6 days and AST are biomarkers for hepatic functionality. of this treatment, rats undergo to spontaneous withdrawal, Data were analyzed by analysis of variance followed by which generally appears between 8 and 14 hours after the last Newman-Keuls post hoc tests when appropriate. ethanol injection. Pioglitazone (0.0, 10 and 30 mg/kg) was 65 Results demonstrated a rapid normalization of all blood administered twice, 12 hours and 1 hour before rating with parameters in patients treated with pioglitaZone (ACT), as drawal symptoms. Behavioural signs of withdrawal included: shown in Table 2. US 8,426,439 B2 51 52 TABLE 2

Mean value of blood tests

TO T1 = 4 weeks T2 = 8 weeks

ACT NTX CTR ACT NTX CTR ACT NTX CTR

MCV 102.26 101.96 102.78 99.82 101.96 103.26 91.37 97.96 104.87 GGT 192.21 167.38 173.58 86.7 91.3S 18167 38.26 42.9 179.47 ALT S1.6 62.7 S8.7 45.6 52.8 52 249 41.8 55.9 AST 69.2 49.3 82.1 51.9 41.5 78.4 29.3 38.3 77 CDT 3.2 3.6 3.8 2.9 3.0 3.7 2.1 2.5 3.1

The decrease of MCV and CDT indicated that patients' etha robust for pioglitazone. As shown in Table 4. In control nol drinking progressively decreased over the two-months of 15 patients, OCDS remained at pre-treatment level. drug treatment. The decrease in GGT, ALT and AST reflected normalisation of hepatic function. In naltrexone treated TABLE 4 patients (NTX), a decrease in MCV and CDT was also observed, but to a lesser extent compared to the pioglitaZone Obsessive compulsive drinking Scale (OCDS) (mean Score values group. Hepatic parameters were also ameliorated by naltrex ACT NTX CTR one, but again the effect of pioglitaZone was more pro T = O 50 49 52 nounced. The Control group that received only psycho T = 1.1 45 47 49 therapy did not show any improvement during the 2-month T = 1.2 37 45 48 treatment. T = 1.3 36 41 49 25 T = 14 34 40 47 Statistical analysis revealed an overall effect of treatment T = 2.1 31 41 47 for all blood parameters measured (MCV, F(2.9)=89.7 T = 2.2 29 43 49 P<0.0001); GGT: F(2.9)=5328 P-0.0001); ALT F(2.9) T = 2.3 28 42 50 =52.57 P-0.0001: AST F(2.9)=771 P-0.0001: CDTF(2, T = 24 28 44 51 9)=26.54 P-0.0001). Post hoc tests revealed that for all the 30 T = 0 corresponds to the beginning of the treatment; five biomarkers a statistical difference (P<0.001) exists T = 1.1 corresponds to month 1, week 1; between controls (psychotherapy alone) and patients treated T = 1.2 corresponds to month 1, week 2, etc. with naltrexone (P<0.001) or with poglitazone (P<0.001). PioglitaZone was more effective than naltrexone in reducing The analysis of variance revealed an overall effect of treat the values of MCV (P<0.001), GGT (P<0.001) and ALT ment (F(2.9)=329.27 P<0.0001). Post hoc tests revealed 35 statistically significant difference between controls and (p<0.001). No significant difference between naltrexone and patients treated with naltrexone (P<0.001) or with poglita pioglitazone were detected for CDT and AST. Zone (P<0.001). Pioglitazone was more effective than naltr Results also showed a progressive decrease in anxiety exone, and a significant difference between pioglitaZone and score during treatment. PioglitaZone showed the highest maltrexone was also observed (p<0.001). effect, as shown in Table 3. In control patients, (psycho The initial Score in the MADRS scale indicated that this therapy alone) anxiety did not diminish during treatment. 40 patient population did not have severe co-morbid depression. During treatment with pioglitaZone, the depression score TABLE 3 decreased starting from the second week of treatment, as shown in Table 5. At week 3, it reached the plateau. However, Anxiety Score obtained using The STAY-Y1 a floor effect might have contributed to rapid plateau. scale (mean score values 45 ACT NTX CTR TABLE 5 T = O 59 61 63 Depression Scale M.A.D.R.S (mean score values T = 1.1 58 61 64 T = 1.2 55 59 62 ACT NTX CTR T = 1.3 S4 53 69 50 T = 14 56 52 65 T = O 21 19 2O T = 2.1 49 51 61 T = 1.1 15 16 18 T = 2.2 47 53 63 T = 1.2 13 18 19 T = 2.3 43 52 67 T = 1.3 10 16 17 T = 2.4 40 51 64 T = 14 11 17 19 55 T = 2.1 12 17 21 T = 0 corresponds to the beginning of the treatment; T = 2.2 13 15 19 T = 1.1 corresponds to month 1, week 1; T = 2.3 10 18 19 T = 1.2 corresponds to month 1, week 2, etc. T = 24 12 19 The analysis of variance revealed an overall effect of treat T = 0 corresponds to the beginning of the treatment; ment (F(2.9)=142.86 P-0.0001). Post hoc tests revealed 60 T = 1.1 corresponds to month 1, week 1; statistically significant difference between controls and T = 1.2 corresponds to month 1, week 2, etc. patients treated with naltrexone (P<0.001) or with poglita The analysis of variance revealed an overall effect of treat Zone (P<0.001). Pioglitazone was more effective than naltr ment (F(2.9)=42.12 P-0.0001). Post hoc tests revealed sta exone, and a significant difference between pioglitaZone and tistically significant difference between controls and patients maltrexone was also observed (p<0.001) 65 treated with pioglitazone (P<0.001) but not naltrexone. Results also showed a progressive decrease in obsessive PioglitaZone was significantly different also from naltrexone compulsive score for alcohol. The effect was extremely (p<0.001) US 8,426,439 B2 53 54 In Summary, the blood parameters determined during the In a within Subject counterbalance order (Latin square course of this study indicated normalization of different alco design), rats were treated with pioglitazone (0.0, 10.0 or 30.0 hol drinking related markers in patients treated with piogli mg/kg) given OS 12 hours and 1 hour before the beginning of taZone or naltrexone. The effect was more robust with piogli the self-administration session. The number of responses to taZone. Patients under psychotherapy alone did not show the active and inactive levers was recorded. A 3-day interval improvements during treatment. This indicates that the dif was allowed between drug testing. During these intervals, ference between Controls and Drug treated patients depended cocaine self-administration was continued to re-establish upon the pharmacological intervention. baseline lever responses. High comorbidity exists between alcohol abuse, anxiety The effect of pioglitaZone administration on cocaine self and depression. The symptoms of these mood-related disor 10 administration was evaluated by mean of a one-way within ders tend to exacerbate during early alcohol detoxification factor ANOVA followed by Newman-Keuls post hoc test. phase, thus contributing to reduced patients compliance. In Treatment with pioglitaZone significantly reduced cocaine this respect, it is highly relevant that pioglitaZone reduces self-administration F(2,5)=13.189 p-0.01. Post hoc tests anxiety and depressive symptoms in alcoholic patients. This revealed a significant (p<0.01) reduction of cocaine self 15 administration at both 10.0 and 30.0 mg/kg of pioglitazone could also explain why after two months of drug administra (FIG.22A). Responses at the left inactive lever were very low tion, all 4 patients under pioglitaZone were still in treatment, and were not modified by pioglitazone treatment (FIG.22B). whereas 2 patients of the control group and 1 of the naltrexone the group dropped out. It is also highly relevant that piogli Example 24 taZone consistently reduced OCDS score. Obsession for alco hol and the urge to drink (which are measured by OCDS Effect of Pioglitazone on Nicotine Use scale) are the major predictors of relapse. These data indicate, therefore, that pioglitaZone has anti-relapse properties. The ability of PPARYagonists and antidepressant to reduce The absence of a placebo treatment in the control (psycho nicotine use was demonstrated in an animal model of nicotine therapy alone) group may have contributed to the high effi 25 addiction. cacy of drug treatments, since the effect of naltrexone was Bupropion hydrochloride (Sigma, Milan, Italy) was dis higher that that normally reported in controlled randomized solved in saline. Nicotine tartrate (Sigma, Milan, Italy) was clinical trials. However, placebo effect cannot account for the dissolved in isotonic saline at a concentration of 0.03 mg/0.1 difference between pioglitaZone and naltrexone efficacy. In ml free base. The pH of the nicotine solution was adjusted to fact, in this case, both groups of patients received pharmaco 30 7 with dilute NaOH. Drug or vehicle solution was infused at logical medications in association with psychotherapy. Based a volume of 0.1 ml over 4s. Pioglitazone was obtained from on this consideration, while it cannot be ruled out that the commercial source: it was suspended in distilled water, and effect ofpioglitazone could have been over estimated to some the resulting Suspension was maintained under constant agi extent in these studies, it is evident that this drug has a sig tation until administration. PioglitaZone was given orally nificant efficacy in controlling alcohol abuse, and its effect 35 (OS) via gavage procedure at 12 hours and 1 hour before the may be Superior to naltrexone. beginning of nicotine self-administration. Male Wistar rats weighing between 180 and 200 g at the Example 23 time of arrival in the lab were used. The rats were housed in groups of three in a humidity- and temperature-controlled Effect of Pioglitazone on Cocaine 40 (22°C.) Vivarium on a 12 h; 12 h reverse light/dark cycle (on, Self-Administration 17:00; off, 05:00) with ad libitum access to food and water. One week after arrival, the rats were subjected to surgery, and The ability of pioglitaZone to reduce cocaine use was dem a silastic catheter was implanted into the right jugular vein. onstrated in a rat model of cocaine addiction. Cocaine hydro Rats (n=9) were trained for one week to self-administer chloride (obtained from the National Institute on Drug Abuse, 45 cocaine in 2-h daily sessions on a fixed-ratio 5 schedule of Bethesda, Md.) was dissolved in sterile physiological saline reinforcement, in which each five response resulted in deliv at a concentration of 0.25 mg/0.1 ml. Drug or vehicle solution ery of 0.25 mg/0.1 ml of fluid cocaine solution. After the was infused at a volume of 0.1 ml over 4s. Pioglitazone Successful completion of cocaine training, rats were allowed obtained from a commercial source was suspended in dis to self-administer nicotine at the 0.03 mg/kg/infusion dose by tilled water, and the resulting Suspension was maintained 50 switching the delivery of cocaine for the delivery of a nicotine under constant agitation until administration. PioglitaZone infusion. Nicotine self-administration training continued was given orally (OS) via gavage procedure 12 hours and 1 until stable baseline of responding was established (less than hour before the beginning of cocaine self-administration. 20% variation for 3 consecutive days calculated for each Male Wistar rats weighing between 180 and 200 g at the single rat). At this point, drug testing began. time of arrival in the lab were used. The rats were housed in 55 In a within Subject counterbalance order (Latin square groups of three in a humidity- and temperature-controlled design), rats were treated with pioglitazone (0.0 and 30.0 (22°C.) Vivarium on a 12 h; 12 h reverse light/dark cycle (on, mg/kg) given OS 12 hours and 1 hour before the beginning of 17:00; off, 05:00) with ad libitum access to food and water. the self-administration session. The number of responses to One week after arrival, rats were subjected to Surgery, and a the active and inactive levers was recorded. A 3-day interval Silastic catheter was implanted into the right jugular vein. 60 was allowed between drug testing. During these intervals, Rats (n=6) were trained to self-administer cocaine in 2-h nicotine self-administration was continued to re-establish daily sessions on a fixed-ratio 5 schedule of reinforcement, in lever responses baseline. which each response resulted in delivery of 0.25 mg/0.1 ml of The effect of pioglitazone administration on nicotine self fluid cocaine solution. Cocaine self-administration training administration was evaluated by mean of a paired t-test. Sta continued until a stable baseline of responding was reached 65 tistical significance was set at PK0.05 (less than 10% variation for 3 consecutive days calculated for After a few training days, Wistar rats acquired robust oper each single rat). At this point, drug testing begun. ant responding for nicotine. As shown in FIG.23A, treatment US 8,426,439 B2 55 56 with 30 mg/kg pioglitaZone significantly reduced nicotine al. 2002: Peltier et al. 1993). Briefly, male Wistar rats are self-administration|ts -2.70 p-0.05). Responses at the left implanted with a permanent Silastic catheter into the right inactive lever was very low and were not modified by piogli jugular vein for intravenous cocaine self-administration (0.25 taZone treatment (FIG. 23B). These results demonstrate that mg/infusion). Using operant self-administration chambers, PPARY agonists are effective in reducing nicotine use. rats are trained to self-infuse cocaine under a fixed ratio 5 schedule of reinforcement (five lever presses to obtain one Example 25 cocaine infusion). Cocaine self-administration training is continued until stable baseline of responding is established. Effect of Pioglitazone and Selected Therapeutic At this point, drug testing is begun. Agents on Nicotine Use 10 In a within Subject counterbalance order (Latin square design), rats are treated with pioglitaZone (predicted dose The ability of PPARY agonists in combination with other therapeutic agents, such as bupropion, nicotine replacement range 5-30.0 mg/kg) or with another PPRYagonist in combi formulations, naltrexone, Varenicicline, and CB1 receptor nation with bupropion, fluoxetine, or buprenorphine. To antagonist/inverse agonists, e.g., rimonabant, rosonabant, 15 evaluate synergism between PPRAY agonists and these latter taranabant, and CP-94.5598, to synergistically reduce nico drugs, the lowest effective dose for each of the compound is tine use is determined in a rat model of nicotine addiction. tested in association. A dose range for bupropion is 10.0- Experiments are conducted using operant self-administra 100.0 mg/kg given OS; a dose range for fluoxetine is 3.0-15.0 tion paradigms, essentially as described in Example 23 (see mg/kg given OS, and a dose range for buprenorphine is 0.1- also Bruijnzeel and Markou, 2003; Rauhut et al 2003). 5.0 mg/kg given IP (Glatz et al. 2002: Peltier et al. 1993: Briefly, male Wistar rats are implanted with a permanent Sorge et al. 2005). The number of responses to the active and Silastic catheter into the right jugular vein for intravenous inactive levers are recorded. A 3-day interval is allowed nicotine self-administration (0.03 mg/infusion). Using oper between drug testing. During these intervals, nicotine self ant self-administration chambers, rats are trained to self-in administration is continued to re-establish lever responses fuse nicotine under a fixed ratio 5 schedule of reinforcement 25 baseline. (five lever presses to obtain one nicotine infusion). Nicotine Data is analyzed by analysis of variance followed by post self-administration training is continued until stable baseline hoc tests (Newman-Keuls or Dunnets) where appropriate. of responding is established. At this point, drug testing is Statistical significance is set at PK0.05. It is expected that begun. these experiments will demonstrate that the combination of a In a within Subject counterbalance order (Latin Square 30 PPARY agonist and any of the listed drugs will act synergis design), rats are treated with pioglitaZone (predicted dose tically in reducing cocaine self-administration, thereby dem range 5-30.0 mg/kg) or with other PPRY agonists in combi onstrating the efficacy of using PPARY and any of these drugs nation with bupropion, nicotine (replacement formulations; to treat addiction. i.e., nicotine patches), naltrexone, Varenicicline, or rimona bant. To evaluate synergism between PPRAY agonists and 35 Example 27 these latter drugs, the lowest effective dose for each of the compounds is tested in association with the PPARYagonist. A Effect of Pioglitazone on Development of Opiate dose range for bupropion is 10-100 mg/given OS; a dose Addiction range for naltrexone is 0.25-2.5 mg/kg given IP; a dose range for Varenicline is 0.25-2.5 mg/kg given IP; and a dose range 40 The ability of PPARY agonists to reduce opiate use and for rimonabant is (0.1-3.0 mg/kg given IP) (Bruijnzeel and prevent opiate addiction is determined in a rat model of opiate Markou, 2003; Rauhut et al. 2003: Steensland Petal. 2007: addiction. Cohen et al. 2005). The number of responses to the active and Experiments are conducted using a conditioned place pref inactive leversis recorded. A 3-day interval is allowed erence apparatus and a well established procedure to study between drug testing. During these intervals, nicotine self 45 morphine induced conditioned place preference (Cicco administration is continued to re-establish lever responses cioppo et al. 2000). Briefly, using a two-chamber place con baseline. ditioning apparatus, male Wistar rats are trained to associate Data is analyzed by analysis of variance followed by post morphine effects to one side of the box and saline to the other hoc tests (Newman-Keuls or Dunnets) where appropriate. side. Multiple groups of rats are used, and the experiment is Statistical significance is set at PK0.05. It is expected that 50 conducted in a between Subject design. Animals are pre these experiments will demonstrate that the combination of a treated with pioglitazone vehicle before the injection of mor PPARY agonist and any of the listed drugs will act synergis phine vehicle. Control group receive morphine and pioglita tically in reducing nicotine self-administration, thereby dem Zone vehicles in both compartments. onstrating the efficacy of using PPARY and any of these drugs The rats are conditioned during a conditioning phase of six to treat addiction. 55 days. Every other day, for three times, rats receive subcuta neous injections of 3 mg/kg of morphine or its vehicle. Piogli Example 26 taZone (5.0-30.0 mg/kg) is injected one hour before mor phine. During conditioning, the guillotine door remains Effect of Pioglitazone and Antidepressants or Opioid closed, and the rats are confined for 1 h in one compartment of Agonist/Antagonist Partial Agonists on Cocaine Use 60 the box. The day following the last conditioning session, rats are allowed to explore the entire box for 15 min, and the time The ability of PPARYagonists in combination with antide spent in each compartment is measured. pressants, bupropion, fluoxetine, or the opioid parial agonist Place preference score (referred to as A time) for each rat is agonist/antagonist, buprenorphine, to synergistically reduce obtained by Subtracting the time spent in the compartment cocaine use is determined in a rat model of cocaine addiction. 65 associated with morphine vehicle to the time spent in the Experiments are conducted using operant self-administra compartment associated to morphine injections. The A time tion paradigms as described in Example 23 (see also Glatz, et values are Submitted to statistical analysis. Data is analyzed US 8,426,439 B2 57 58 by analysis of variance followed by post-hoc tests (Newman experimental stroke: in vivo evidence against an antiexci Keuls or Dunnets) where appropriate. Statistical significance totoxic mechanism. J. Neurosci. 17, 6939-694. is set at PKO.05. Burstein S. PPAR-gamma: a nuclear receptor with affinity for It is predicted that morphine will elicit a marked condi cannabinoids. Life Sci. 2005; 77:1674-84. tioned place preference, and treatment with pioglitaZone will Cernuda-Morollon, E. Rodriguez-Pascual, F., Klatt, lamas, reduce the acquisition of morphine-induced place condition Perez-Sala, D., 2002. PPAR agonists amplify iNOS ing (see for review; Sanchis-Segura and Spanagel 2006) expression while inhibiting NF-kappaB: implications for These results will demonstrate the ability of PPARYagonists mesangial cell activation by cytokines. J. Am. Soc. Neph to prevent the development of addiction to opioids and more rol. 13, 2223-2231. specifically to morphine. 10 The various embodiments described above can be com Childress, A. R. Ehrman, R. N., McLellan, A. T., and bined to provide further embodiments. All of the U.S. patents, O'Brien, C. P. Conditioned craving and arousal in cocaine U.S. patent application publications, U.S. patent applica addiction: A preliminary report, in NIDA Research Mono tions, foreign patents, foreign patent applications and non graph 81, US Government Printing Office, Washington, patent publications referred to in this specification and/or 15 D.C., 1988, 74. listed in the Application Data Sheet, are incorporated herein Chinetti G. Fruchart J. C., Staels B. (2000). Peroxisome pro by reference, in their entirety. Aspects of the embodiments liferator-activated receptors (PPARs): nuclear receptors at can be modified, if necessary to employ concepts of the the crossroads between lipid metabolism and inflamma various patents, applications and publications to provide yet tion. Inflamm Res 49: 497-505. further embodiments. Ciccocioppo R. Angeletti S., Sanna P. P. Weiss F., Massi M. These and other changes can be made to the embodiments Effect of nociceptin/orphanin FQ on the rewarding prop in light of the above-detailed description. In general, in the erties of morphine. EurJ Pharmacol. 2000; 404: 153-9. following claims, the terms used should not be construed to Ciccocioppo R. Katner S. N. Weiss F. Relapse induced by limit the claims to the specific embodiments disclosed in the alcohol-associated environmental stimuli after extinction specification and the claims, but should be construed to 25 in rats. Alcohol Clin Exp Res 1999-c; 23(Suppl):52A. include all possible embodiments along with the full scope of Ciccocioppo R. Panocka I., Polidori C., Regoli D., Massi M. equivalents to which Such claims are entitled. Accordingly, Effect of nociceptin on alcohol intake in alcohol-preferring the claims are not limited by the disclosure. rats. Psychopharmacology 1999-a; 141:220-4. Ciccocioppo R., Sanna P. P. Weiss F. 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Peroxisome proliferator-activated peroxisome proliferator-activated receptor gamma receptor (PPAR) alpha activation increases adiponectin (PPARYagonist) effective for the treatment of the addic receptors and reduces obesity related inflammation in adi tion, wherein the PPARY agonist is a thiazolidinedione pose tissue: comparison of activation of PPARalpha, (TZD). 10 2. The method of claim 1, wherein the TZD is selected from PPARgamma, and their combination. Diabetes. 54:3358 the group consisting of pioglitaZone, rosiglitaZone, ciglita 3370. Zone, troglitaZone, englitaZone, rivoglitaZone and darglida Volpicelli J. R. Alterman A.I., Hayashida M., O'Brien C. P. ZO. Naltrexone in the treatment of alcohol dependence. Arch 3. The method of claim 2, wherein the TZD is pioglitazone. Gen Psychiatry 1992:49:876-880. 15 4. The method of claim 1, further comprising providing an Wallace, B. C., Psychological and environmental determi additional therapeutic agent, wherein each of the PPARYago nants of relapse in crack cocaine Smokers, J Subst Abuse nist and the additional therapeutic agent contribute to the Treat, 6, 95, 1989. effective treatment or relapse of the addiction. Weiss, F. and Ciccocioppo, R., Environmental stimuli 5. The method of claim 4, wherein said additional thera potently reinstate alcohol-seeking behaviour: Effect of 20 peutic agent is selected from the group consisting of an repeated alcohol intoxication, Soc. Neurosci. Abstr., 25. opioid antagonist, a mixed opioid partial agonist/antagonist, 1081, 1999. an antidepressant, an antiepileptic, an antiemetic, a corti Weiss F., Ciccocioppo R., Parsons L. H. Katner S. Liu X. cotrophin-releasing factor-1 (CRF-1) receptor antagonist, a Zorrilla E. P. Valdez. G. R., Ben-Shahar O. Angeletti S., selective serotonin-3 (5-HT3) antagonist, a 5-HT2A/2C Richter R. R. Compulsive drug-seeking behaviour and 25 antagonist, and a cannabinoid-1 (CB1) receptor antagonist. relapse. Neuroadaptation, stress, and conditioning factors. 6. The method of claim 5, wherein the additional therapeu Ann NYAcadSci 2001; 937:1-26. tic agent is an opioid antagonist selected from the group Weiss F., Lorang M.T., Bloom F. E., Koob G. F. Oral alcohol consisting of naltrexone and nalmefene. self-administration stimulates dopamine release in the rat 7. The method of claim 5, wherein the additional therapeu 30 tic agent is an antidepressant selected from the group consist nucleus accumbens: genetic and motivational determi ing of fluoxetine, mirtazapine, and bupropion. nants. J Pharmacol Exp Ther 1993; 267:250-8. 8. The method of claim 5, wherein the additional therapeu Weiss, F., Maldonado-Vlaar, C.S., Parsons, L.H., Kerr, T. M., tic agent is an antiepileptic selected from the group consisting Smith, D. L., and Ben-Shahar, O., Control of cocaine of benzodiazepines, barbituates, valproates, GABA agents, seeking behaviour by drug-associated Stimuli in rats: 35 iminostilibenes, hydantoins, NMDA antagonists, Sodium Effects on recovery of extinguished operant responding channel blockers and Succinamides. and extracellular dopamine levels in amygdala and nucleus 9. The method of claim 8, wherein the additional therapeu accumbens, Proc. Natl. Acad. Sci. USA, 97, 4321, 2000. tic agent is an antiepileptic selected from the group consisting Wise R. A. Drug activation of brain reward pathways. Drug of topiramate, levetiracetam, gabapentin, alprazolam, chlo Alcohol Depend 1998: 51:13-22. 40 rdiazepoxide, cholraZepate, clobazam, clonazepam, diaz Wu Z., Bucher N. L., Farmer S. R. (1996). Induction of epam, halazapam, lorazepam, oxazepam, prazepam, amobar peroxisome proliferator-activated receptor-gamma during bital, mepobarbital, methylphenobarbital, pentobarbital, the conversion of 3t3 fibroblasts into adipocytes is medi phenobarbital, primidone, Sodium Valporate, valproic acid, ated by C/EBPbeta, C/EPBdelta, and glucocorticoids. Mol valproate semisodium, Valpromide, losigamone, pregabalin, Cell Biol 16:4128-4136. 45 retigabine, rufinamide, vigabatrin, carbamazepine, oXcarba Yamauchi, T., et al. 2001. The fat derived hormone adiponec Zepine, fosphenytoin Sodium, mephenytoin, phenytoin tin reverses insulin resistance associated with both lipoat Sodium, harkoseramide, lamotrigine, ethoSuximide, meth rophy and obesity. Nat. Med. 7:941-946. Suximide, phensuximide, acetazolamide, briveracetam, CBD Yamauchi, T., et al. 2003. Cloning of adiponectin receptors cannabis derivative, clomthiazole cdisilate, divalproex that mediate antidiabetic metabolic effects. Nat. Med. 423: 50 Sodium, felbamate, isovaleramide, lacosamide, lamotrigine, 762-769. methaneSulphonamide, talampanel, tiagabine, Safinamide, Yu X, Shao X. G., Sun H. Li Y. N.Yang J., Deng Y.C., Huang seletracetam, Soretolide, Stiripentol, Sultiam, Valrocemide, Y. G. Activation of cerebral peroxisome proliferator-acti and Zonisamide. Vated receptors gamma exerts neuroprotection by inhibit 10. The method of claim 5, wherein the additional thera ing oxidative stress following pilocarpine-induced status 55 peutic agent is a CRF-1 receptorantagonist that is antalarmin. epilepticus. Brain Res. 2008: 1200C:146-58. 11. The method of claim 5, wherein the additional thera Yu, J. G., et al. 2002. The effect of thiazolidinediones on peutic agent is a selective serotonin-3 (5-HT3) antagonist that plasma adiponectin levels in normal, obese, and type 2 is ondansetron. diabetic subjects. Diabetes. 51:2968-2974. 12. The method of claim 5, wherein the additional thera Zalcman S., Savina I., Wise R. A. (1999). Interleukin-6 60 peutic agent is a cannabinoid-1 (CB-1) receptor antagonist increases sensitivity to the locomotor-stimulating effects selected from the group consisting of rimonabant and tanara of amphetamine in rats. Brain Res 847: 276-283. bant. Zhao, M. L., Brosnan, C. F. Lee, S.C., 2004. 15-Deoxy-delta 13. The method of claim 5, wherein the additional thera (12-14)-PG.J2 inhibits astrocyte IL-1 signaling: inhibition peutic agent is a mixed opioid agonist/antagonist that is of NF-kappaB and MAP kinase pathways and suppression 65 buprenorphine. of cytokine and chemokine expression. J. Neuroimmunol. 14. A method of treating or reducing relapse use of alcohol, 153, 132-142. comprising providing an effective amount of a peroxisome US 8,426,439 B2 65 66 proliferator-activated receptor gamma (PPARY) agonist to a 25. The method of claim 19, wherein the additional thera Subject who has undergone a period of abstinence from, or peutic agent is a selective serotonin-3 (5-HT3) antagonist that limited or reduced use of alcohol, wherein the PPARYagonist is ondansetron. is a thiazolidinedione (TZD). 26. The method of claim 19, wherein the additional thera 5 peutic agent is a cannabinoid-1 (CB-1) receptor antagonist 15. The method of claim 14, further comprising providing selected from the group consisting of rimonabant and tanara to the Subject an additional therapeutic agent, wherein each of bant. the PPARY agonist and the additional therapeutic agent con 27. The method of claim 19, wherein the additional thera tribute to the effective reduction of the relapse use. peutic agent is a mixed opioid agonist/antagonist that is 16. The method of claim 14, wherein the subject previously buprenorphine. reduced or eliminated use of alcohol in response to treatment 10 28. The method of claim 15, wherein the PPARYagonist is with an effective amount of an anti-addiction treatment, and pioglitaZone and the additional therapeutic agent is naltrex wherein the Subject is no longer exposed to an effective OC. amount of the anti-addiction treatment. 29. The method of claim 14, wherein the relapse use is 17. The method of claim 14, wherein the TZD is selected stress-induced. 15 30. The method of claim 16, wherein the subject is no from the group consisting of pioglitaZone, rosiglitaZone, longer exposed to an effective amount of the anti-addiction ciglitaZone, troglitaZone, englitaZone, rivoglitaZone and dar treatment because the subject has become conditioned to the glidaZone. anti-addiction treatment. 18. The method of claim 17, wherein the TZD is pioglita 31. The method of claim 16, wherein the subject is no ZO. longer exposed to an effective amount of the anti-addiction 19. The method of claim 15, wherein the additional thera treatment because the subject has reduced or eliminated peutic agent is selected from the group consisting of an exposure to the anti-addiction treatment. opioid antagonist, a mixed opioid partial agonist/antagonist, 32. A method of reducing one or more symptoms associ an antidepressant, an antiepileptic, an antiemetic, a corti ated with physiological withdrawal from alcohol, comprising cotrophin-releasing factor-1 (CRF-1) receptor antagonist, a 25 providing an effective amount of a peroxisome proliferator selective serotonin-3 (5-HT3) antagonist, a 5-HT2A/2C activated receptor gamma (PPARY) agonist to a Subject under antagonist, a 5-HT2A/2C antagonist, and a cannabinoid-1 going physiological withdrawal from alcohol, wherein the (CBI) receptor antagonist. PPARY agonist is a thiazolidinedione (TZD). 20. The method of claim 19, wherein the additional thera 33. The method of claim 32, further comprising providing peutic agent is an opioid antagonist selected from the group 30 an additional therapeutic agent to a subject undergoing physi consisting of naltrexone and nalmefene. ological withdrawal from an addictive agent, wherein each of 21. The method of claim 19, wherein the additional thera the PPARY agonist and the additional therapeutic agent con peutic agent is an antidepressant selected from the group tribute to reducing one or more symptoms associated with consisting of fluoxetine, mirtazapine, and bupropion. physiological withdrawal from the addictive agent. 22. The method of claim 19, wherein the additional thera 35 34. The method of claim 32, wherein the TZD is selected peutic agent is an antiepileptic selected from the group con from the group consisting of pioglitaZone, rosiglitaZone, sisting of benzodiazepines, barbituates, valproates, GABA ciglitaZone, troglitaZone, englitaZone, rivoglitaZone and dar agents, iminostilibenes, hydantoins, NMDA antagonists, glidaZone. Sodium channel blockers and Succinamides. 35. The method of claim 34, wherein the TZD is pioglita 23. The method of claim 22, wherein the additional thera 40 ZO. peutic agent is an antiepileptic selected from the group con 36. The method of claim 33, wherein the additional thera sisting of topiramate, levetiracetam, gabapentin alprazolam, peutic agent is selected from the group consisting of an chlordiazepoxide, cholrazepate, clobazam, clonazepam, opioid antagonist, a mixed opioid partial agonist/antagonist, diazepam, halazapam, loraZepam, oxazepam, prazepam, an antidepressant, an antiepileptic, an antiemetic, a corti amobarbital, mepobarbital, methylphenobarbital, pentobar 45 cotrophin-releasing factor-1 (CRF-1) receptor antagonist, a bital, phenobarbital, primidone, Sodium Valporate, Valproic selective serotonin-3 (5-HT3) antagonist, a 5-HT2A/2C acid, Valproate semisodium, Valpromide, losigamone, pre antagonist, and a cannabinoid-1 (CB1) receptor antagonist. gabalin, retigabine, rufinamide, vigabatrin, carbamazepine, 37. A method of treating an addiction to alcohol, compris oXcarbazepine, fosphenytoin Sodium, mephenytoin, pheny 1ng: toin Sodium, harkoseramide, lamotrigine, ethoSuximide, 50 determining that a subject has an addiction to alcohol; and methSuximide, phensuximide, acetazolamide, briveracetam, providing to the Subject an amount of a thiazolidinedione CBD cannabis derivative, clomthiazole edisilate, divalproex (TZD) effective for the treatment of the addiction to Sodium, felbamate, isovaleramide, lacosamide, lamotrigine, alcohol. methaneSulphonamide, talampanel, tiagabine, Safinamide, 38. The method of claim 37, further comprising providing seletracetam, Soretolide, Stiripentol, Sultiam, Valrocemide, 55 an additional therapeutic agent, wherein each of the TZD and and Zonisamide. the additional therapeutic agent contribute to the effective 24. The method of claim 19, wherein the additional thera treatment of the addiction. peutic agent is a CRF-1 receptor antagonist that is antalarmin. k k k k k UNITED STATES PATENT AND TRADEMARK OFFICE CERTIFICATE OF CORRECTION PATENT NO. : 8,426,439 B2 Page 1 of 1 APPLICATIONNO. : 12/1 01943 DATED : April 23, 2013 INVENTOR(S) : Roberto Ciccocioppo It is certified that error appears in the above-identified patent and that said Letters Patent is hereby corrected as shown below:

COLUMN LINE ERROR In The Specification 19 45-46 “papvereturn should read-papaveretum-- 21 29 “HDI Should read --HDL 30 46 “associated withdrawal should read-associated with withdrawal 30 65 "asSociated withdrawal should read-associated with withdrawal-- 62 40 “19:334 Should read --119:334-- In The Claims 64 49 "codisilate should read --edisilate-- 65 28 “(CB-1) should read --(CB1)-- 66 5 “(CBI) should read --(CB1)--

Signed and Sealed this Tenth Day of May, 2016 74.4.4.2% 4 Michelle K. Lee Director of the United States Patent and Trademark Office